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Do you address cognitive issues as a therapist? If so, what do you do?

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Physical Therapist

Answer transcribed from Brightway's interview with physical therapist Susan Little:

It's definitely not the bread and butter of my practice as a physical therapist. When I lecture to students, I always laugh that I need books of cognition for dummies because it's not the main part of my therapy. The main part of my education with brain injury covers recovery cognition rules. If you can imagine somebody at a very low level of responsiveness, as a physical therapist, I sure as heck am working in the context of my therapy on their ability to follow verbal commands and their ability to respond to commands as that individual progresses through their recovery. This includes challenging them from a memory point of view in the context of my mobility tasks, such as having them go on a scavenger hunt where they have to remember the items in the list. Just like how as you're going into the grocery store, you might have to remember that you need peanut butter, bread, and milk, they need to work on their memory while they're working on their mobility.


In a brain injury team, we cross disciplines often. I don't pretend to be an expert on cognition, that's the rest of my buddies in my “village”. I'll ask the occupational therapist how our client is doing with their vision and if I give them this challenge with their walking, is that a difficult but doable thing to do. I'll ask the speech therapist if it’s reasonable for me to ask them to work on a certain memory or language task in the context of my mobility tasks. My point being is we work together. None of us are experts in all of the areas required for recovery from brain injury. We all have our area of expertise but we lean on each other and incorporate all of those challenges because it takes a village to encourage recovery and to maximize recovery from brain injury. 


I would say that the speech therapist or the neuropsychologist are the two that do most of the cognitive rehab. I have to say occupational therapy as well will work an awful lot on incorporating those skills with activities of daily living. Again, we cross the lines, but if I had to name the expert, I would say the speech therapist and the neuropsychologist. The second place would be the occupational therapist. Way down in tenth place would be the physical therapist but we do our best.

Clinical Specialist

Answer transcribed from the Brightway Answers interview with clinical specialist Marlene Rivera:

Yes, recreational therapists do address cognitive issues. When we think about free time management, what we're doing is evaluating an individual's cognitive capacity to effectively manage their free time.  We may be looking at their ability to effectively engage in a specific recreation and leisure pursuit, as your cognition may be impacted in how you're able to successfully participate in these activities.  There are also individuals who have a difficult time generating ideas about what they want to do.

We look at what kind of compensatory strategies we can introduce to help with these things. It may be presenting individuals with written information, it may be communicating in a different way.  Initially we will conduct an assessment and based on the outcome of that assessment, a recreation therapist will test and implement maybe some adaptive equipment or compensatory strategies that match an individual's current interests and their current abilities.

speech language pathologist

Absolutely. As a speech-language pathologist, one of the questions I answer during an initial assessment is if the person's ready for cognitive therapy.

Neuroplasticity lets us view our brain as a muscle, so to work on cognition we want to exercise our cognitive abilities and challenge ourselves - it should be difficult.

I use a lot of puzzles like deductive reasoning puzzles, which targets many cognitive processes. It looks sort of like a sudoku. Process of elimination is used to solve the puzzle, and there are some views that are presented that are straightforward, and some that are more difficult. So we're looking for the brain to make connections and eliminate something that's unnecessary and get to the answer.

I also do mental manipulation. For example, alphabetizing random words. So I would give you apple, cat, banana, and would ask you to put them in alphabetical order. Or if I give you three numbers, you would put them in the correct order. Mental manipulation or mental flexibility is computation of a problem. You could do numeric computations or work with words to tap into the memory and processing.

We also work on abstract reasoning and inferencing, deductive reasoning, divergent reasoning, and convergent reasoning. For example, I might be asking a patient to name as many items belonging to a specific category given one minute, like as any as many animals as you could think of in one minute. And we always start from simple and concrete and move to more complex and abstract.

Problem solving and cause and effect are needed for daily living, so these get incorporated into all of our exercises.

Speech-Language Pathologist

Answer transcribed from the Brightway Answers interview with speech-language pathologist Amber Kloess:

Yes, as a speech-language pathologist, I work with patients on cognition.

What I work on depends on where you are in your recovery.  If you’re newly injured after a brain injury, speech-language pathologists will take a rehabilitative approach - that's where we target skills directly through more structured tasks. For attention, for example, there's attention process training - a whole system to follow to order to build up attention.  There are short term and working memory exercises, direct coaching, direct feedback, errorless learning - where that feedback is almost instantaneous so they can correct the actions.

Later on in recovery, we tend to move toward the compensatory approach to treatment.  That means finding the strategies that will improve functioning in daily life.  There are two sets of those strategies.  The first is external - like implementing a calendar or a planner to help to recall appointments, charts to manage bills, writing notes, to-do lists, sticky notes, memory journals, things like that.  Then there are the internal strategies which happen inside of you. That can be associations you can make to help recall people's names. For instance, if you met someone at a friend's house whose name is Tony and he was tall, that's “Tall Tony”.  These strategies can help you to remember their name later.

Many things center around a goal-plan-do-review model.  That is for patients that I help to set reasonable goals with their input.  They will plan how to accomplish that goal, reflect on it, execute it, and follow through with the task.  I feel that's really helpful to improve awareness and also self-esteem, knowing that you're able to accomplish a goal after you planned it out.

Family involvement is also key for that, especially with working on functional skills.  The therapist can't be in the home 24 hours a day, so I coach families through some things and provide homework or activities that they can do within the home.

I’ll also help patients to establish systems like timers on the stove so you don't burn your food or introduce the planner and make sure that they fill it out.

I also recommend just engaging in cognitively stimulating tasks at home, but know your limits so you don't overdo it, take breaks to prevent overload and cognitive fatigue.