Categories of Care: What They Are, and Why They Matter

Using Help to Pinpoint Proper Care Following Brain Injury After a brain injury, many survivors require help in one form or another. Some people require extensive support, while others need only a limited amount of services. This is often reduced with time and rehabilitation, but chronic complications with some injuries may create an increased need for assistance years after a diagnosis is made. Identifying the help that is needed is often a fluid, unfolding process; but being aware of the different categories of caregiving options can provide guidance when searching for the correct level of support. In persons with brain injury, the amount of outside assistance required to carry out essential functions in everyday life is formally known as acuity. An interdisciplinary team of neurological professionals can help determine a person’s acuity by identifying what, if any, supports are needed. By reviewing documentation and collaborating with caregivers who provide supporting information about behaviors they observe from their clients or loved ones, risks, and care needs are identified relating to three specific areas:

  • Tasks of Self-Care: Personal care activities like dressing and bathing are often referred to as basic activities of daily living (BADL). More advanced tasks that require deeper thinking elements, such as scheduling or budgeting, are considered independent activities of daily living (IADL). If an individual needs assistance when carrying out either — or both — of these categories of self-care tasks, they are in need of what’s called attendant care. Attendant care provides hands-on assistance with physically managing daily routines that may be limited by weakness, fatigue, or thinking problems like memory or attention. Generally, attendant care is hands-on care provided to make up for physical limitations of an injury.
  • Replacement Services: Some survivors struggle with effectively carrying out typical responsibilities around the home, such as yard work, childcare, or home repairs. In these cases, they may need to assign or purchase these services for others to do. These needs are called replacement services, and are considered another category of caregiver support.
  • Protective Supervision: Brain injury can create an inability for individuals to recognize problems or advocate for help. Protective supervision is care that stands in reserve, monitoring for emerging risks, and stepping in with support when an injured person demonstrates behaviors that might lead to harm if left unchecked. Protecting a person from fall risk when he or she is unaware of poor motor skills, monitoring a meal for choking risks, or providing orientation support for a person with confusion are examples of why protective supervision is often necessary.
Acuity isn’t only about identifying the type of help an individual needs, however. Acuity also determines the coverage and intensity of this assistance. In other words, it identifies how much and how demanding the support can be. Coverage refers to the portion of the day or specific times when help is needed. This may be expressed as supervision hours (e.g. up to six hours daily), or for specific events or portions of the day, like during mealtimes or supervision during waking hours only. Intensity considers the demand of a caregiver’s attention. In hospitals and rehab facilities alike, this is often referred to as a ratio of supporting persons to the number of people they are helping. People with severe injuries may need someone to provide assistance exclusively to them (1:1 support), while others may be safe with an assistant who helps them along with two others at the same time (3:1 support). Intensity also factors in the distance these caregivers can be from their patients; whether that be to stay within an arm’s length at all times, or simply making sure an individual is within their line of sight. Being familiar with each category of care — and identifying exactly where a patient falls within them — can greatly help when advocating for the correct and necessary support an individual needs. Professional assessments that pinpoint the precise what, when, and how much help a person requires, as well as careful documentation by healthcare providers and caregivers that support these findings, not only improves opportunities for ongoing coverage from funders, but also allows a person the best chance at success and fulfillment in their lifestyle following brain injury. Martin J. Waalkes, Ph.D., ABPP(rp), CBIS-T
Director of Neuro Rehabilitation
Licensed Psychologist

Hope Network Neuro Rehabilitation

Being Mindful on Independence Day

Independence Day can be a time to celebrate for many. It is a time to spend with family, enjoy rest and relaxation, and even revel in the excitement of fireworks. For those with a brain injury, though, this holiday may look and feel very different. Brain injury can bring many unpleasant symptoms, including physical changes (fatigue, pain), photophobia (light sensitivity), overstimulation to noises and crowds, and many emotional changes like anxiety and depression. Despite all of the changes that survivors feel on the inside, brain injury is often referred to as “an invisible injury” because others may not recognize the individual has sustained a brain injury. Many of the cognitive, emotional, and physical changes are unnoticeable to others on the outside. What used to be pleasant holidays and get-togethers, like Independence Day, may pose a variety of challenges for those with brain injury. Some individuals with brain injury may even be living with a mental health condition known as Post-Traumatic Stress Disorder (PTSD). PTSD can develop after exposure to a traumatic or life-threatening event, such as a car accident, a fall, or combat-related incident in the military. PTSD may mean that someone experiences flashbacks, nightmares, or is overly aware of their surroundings. For Independence Day, fireworks may be an unpleasant reminder of the trauma they experienced. The good news is there is hope for those with brain injury to endure and enjoy the holidays once again, with small changes to their usual traditions. Here are a few tips for individuals with brain injury, as well as their support system, for navigating this upcoming holiday. Tips for Individuals with Brain Injury
  • Plan ahead: speak with family and friends to identify a safe and enjoyable way to enjoy the holiday
  • Manage fatigue: be well-rested leading up to the celebration and take breaks when needed
  • Reduce sensory overstimulation: taking noise-cancelling earphones, sunglasses, or hats may reduce the sensory input during fireworks and around large crowds
  • Choose your location carefully: if you choose to enjoy a live celebration of fireworks, choose a seat furthest away from the action
  • Explore your options: forego the live fireworks and watch them from the comfort (and quietness) of your home
Communication Tips for Brain Injury Supporters
  • Ask first: ask the person with brain injury their preference for activities for the holiday
  • Offer support: if they choose to sit out on certain activities, join them and provide company
  • Find a balance: compromise on traditions and swap out events with new activities your loved one is most comfortable with
  • Have a back-up plan: identify alternative activities if your loved one is not feeling up to the festivities at that time
  • Plan your escape: in the event that your loved one is triggered by something during the activity, have a plan for minimizing distress and moving to a more comfortable place
These are just a few ways for everyone to show their understanding and support for individuals with brain injury during this holiday season. Dr. Amanda Lopez PhD, LP, CBIS
Psychology Supervisor
Origami Brain Injury Rehabilitation Center

To Drive or Not to Drive? Getting Behind the Wheel after a Traumatic Brain Injury

Driving is the ultimate symbol of independence and control. Losing the ability to drive after a traumatic brain injury (TBI) may feel devastating and can greatly affect a person’s quality of life during recovery. But considering that driving is one of the most dangerous activities we do on a daily basis, the decision of if and when to return to driving can be complex. Safe driving requires a number of skills which may be altered after a TBI including:
  • Visual acuity and perception
  • Memory to recall directions or destination
  • Hand-eye coordination
  • Reaction time
  • Safety awareness and judgment
  • Sustained and alternating attention
  • Range of motion and strength of arms, legs and neck
  • Confidence behind the wheel
  • Anxiety level
Research indicates that 50-70% of people with moderate to severe TBI will return to driving regardless of recommendations from their healthcare team or safety concerns (Schultheis & Whipple, 2014) (Classen, 2009). That’s why it’s important for TBI survivors to discuss and address return to driving with their healthcare team openly and honestly. As a first step in the path towards returning to drive, therapists are able to incorporate pre-driving skills into therapy sessions. These pre-driving therapy sessions focus on remediating, refining and strengthening any of the above skills that may impact driving ability or safety. Many rehabilitation providers offer pre-driving screenings or programming to jumpstart the process. After pre-driving skills are mastered, TBI survivors can benefit from working with a Certified Driving Rehabilitation Specialists (CDRS) for on-the-road training. These experts also assist in obtaining and practicing the use of adaptive equipment. Various types of equipment such as hand controls and adaptive steering wheels can be used if traditional foot pedals or wheels are not optimal. A CDRS can even help coordinate securing an adaptive vehicle with ramp access and modified seating if necessary. Safe return to driving after a traumatic brain injury is possible with the right training and resources. The first step toward safely getting behind the wheel after a traumatic brain injury is starting a conversation with the rehabilitation team.

References:

  • Classen, S. e. (2009). Traumatic brain injury and driving assessment; and evidence-based literature review. American Journal of Occupational Therapy, 580-591.
  • Schultheis, M. T., & Whipple, E. (2014). Driving after traumatic brain injury:evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 176-183.
Angela West, MSOT, OTRL
Occupational Therapist + Therapy Best Practices Coordinator
Special Tree Rehabilitation System

Brain Injury Association of Michigan: One-Sided No-Fault Reform Bill Doesn’t Go the Distance

Association joins Gov. Whitmer and House Democrats in calling for strong consumer protection, permanent rate relief, and long-term solutions

FOR IMMEDIATE RELEASE For more information:
Janna Wilson
(248) 810.229.5880 LANSING, Mich. (May 9, 2019) – The passage of SB1 and HB 4397 may now be a reality, but those who protect consumers want more. In response, President and CEO of Brain Injury Association of Michigan (BIAMI) Tom Constand issued the following statement: “We thank Gov. Whitmer and House Democrats for standing up for Michigan consumers in rejecting the bill as written. Although it addresses the basic tenets of reform, it does little to ensure a permanent solution. Moreover, instead of allowing for constructive committee discussion and debate, this 82-page bill was railroaded through the House in the middle of the night with no opportunity for thoughtful deliberation.” “We are looking for fair, reasonable and sustainable legislation that provides strong consumer protections, offers immediate rate relief and protects benefits for the insured. This bill provides weak concessions that don’t ensure ongoing rate relief, provides a pittance of coverage options, and will leave survivors and their families even more exposed to the unethical and predatory practices of the insurance industry. We must do better than this.” About the Brain Injury Association of Michigan
The Brain Injury Association of Michigan is dedicated to enhancing the lives of those affected by brain injury through education, advocacy, research and local support groups, and to reducing the incidence of brain injury through prevention. Founded in 1981, Brighton, Michigan-based BIAMI is a national leader in its efforts on behalf of the approximately 200,000 Michigan residents who live with disabilities as a result of a brain injury.

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Brain Injury Association of Michigan
7305 Grand River, Suite 100
Brighton, MI 48114-7379
BIAMI.ORG

If you support Governor Whitmer, please add your name to our petition on Change.org.

Triangulation – What Is It and How Does It Apply to the Role of Caregiver

As caregivers, we are each drawn to the work we do for a reason. It may be because we simply like to help, have someone in our lives suffering from a disease or an injury, or are just stopping along the way to get to another spot. Whatever the reason, our jobs involve helping people. This can be very rewarding and enriching – it can also be troubling, stressful and distressing. One tactic we come across in the world of therapy is triangulation – a form of manipulation where a person will not communicate directly with another person, instead they use a third person to relay the information to the second person – thus forming a triangle. Triangulation is a concept primarily used in trauma-based therapy, taught to mental health professionals specifically trained to work with individuals who have experienced a traumatic incident, such as a car accident, fire, death of a loved one, etc. The way these individuals perceive life and relationships can be drastically influenced by that experience.
This has much to do with how the brain is wired, through social and emotional experience, and how social experiences have affected the individual. The act of triangulation can be intentional or unintentional – a very complicated cycle that negatively impacts everyone involved. Triangulation can be common in many aspects of our lives, but as a psychologist in the world of brain injury rehabilitation, I see it quite often. To have a triangle, you must have three people: a victim, a persecutor, and a rescuer.
Victim: “The good guy”. No voice, no power. In this frame of mind, the victim does have power and a voice but are afraid to use them. Persecutor: “The bad guy”. The attacker, the one who bothers the victim. It could include allowing the victim to experience the natural consequences of their choices or behaviors. Rescuer: “The hero”. Swoops in and takes care of the victim’s problem – but at the same time ensures the victim never finds their own voice or personal power. Let’s use the characters in the movie The Wizard of Oz as an example... Dorothy – the victim. Riding in a house which drops and kills the Wicked Witch; obtains the Ruby Slippers. Wicked Witch of the West – the persecutor. Unhappy about sister’s death, but more importantly – wants the Ruby Slippers. Glenda the “Good Witch” – Dorothy’s potential first rescuer. Glenda is good, and tells Dorothy how to solve her problem but doesn’t do it for her. In the movie, Dorothy picks up potential rescuers along the way – the Tin Man, the Cowardly Lion and the Scarecrow – all victims of their own life circumstances. Each of them do their best to rescue one another from their fears. We also see several persecutors for the victims, each of whom are looking for help/rescuing from the Wizard of Oz.
“When we cast ourselves in the victim role, we often feel helpless, hopeless, powerless, inept, etc. Sometimes, we may think “I can’t do it, I need you to do it.”
Fast forward to the Emerald City, where the best rescuer is believed to reside – the Wizard. Dorothy asks the Wizard for help, but is denied. [Oh, no, that isn’t supposed to happen – the Wizard (rescuer) is supposed to help me.] For the Wizard, his role quickly transitions from rescuer to persecutor.
“Now the victim has to find a new rescuer.”
In the case of the Wizard of Oz, that person becomes Glenda. Glenda helps Dorothy rescue herself by finding her voice and enacting her power to dissolve the witch with a bucket of water, and with three taps of the shoes, we see Dorothy back home.
“Rescuers, understand: if you are not able to rescue your victim, the victim doesn’t like how you rescued them, or other reasons – you – the rescuer is now becomes the persecutor.”
So, how do we break out of the triangle?
  • Support, don’t rescue. If someone comes to you to rescue them, assist them in figuring out how to solve the problem themselves.
  • Refer the victim back to the person with whom they are having the problem.
  • Help the victim find their voice. Role play what they could say by using the “I” message concept:
When your [insert description of behavior], I feel [insert name the emotion], I want [insert description of replacement behavior]. Example:
“When you act like a jerk, you make me angry, I want you to stop” will serve to incite more conflict versus help resolve. A different approach might be “when you keep your headphones on when I am trying to talk to you, I feel frustrated. I would like you to take the headphones off.”
We can also use this method to communicate positives. “When you take off your headphones when I’m trying to talk to you, I feel appreciative, please keep it up!” Some helpful reminders:
  • When we say “I feel,” we’ve taken responsibility for our own emotions, versus when we say “you make me feel,” we give all the power to the other person.
  • Make sure the description of the behavior is without opinion or judgement.

References:

Kimberly McGowan, MA, LLP, CBIS
Limited License Psychologist
Hope Network Neuro Rehabilitation

Celebrating Brain Injury Awareness Month

Brain injury is often referred to as an “invisible” injury or disability since the effects of the injury are not always visible or immediately evident. However, to anyone who has suffered a brain injury, or to those that care about someone who has, the effects of brain injury are complex and can pervade many aspects of the individual’s life. Brain injury can be difficult to understand, the symptoms can be significant, and the rehabilitation process can be extensive. We are proud to join brain injury survivors, caregivers, and supporters in celebrating Brain Injury Awareness Month. For decades, the Brain Injury Association of America (BIAA) has led a nationwide public awareness campaign during the month of March to de-stigmatize brain injury through outreach and education.
According to the Brain Injury Association of Michigan (BIAMI), in Michigan alone, 58,500 people sustain a brain injury each year. The truth is that no one plans for a brain injury, but brain injuries can happen to anyone, at any time. Please join us this month as we spread awareness and educate others on the definition of brain injury, its causes, and where to seek proper rehabilitative care.

What is a Brain Injury?

Just as there are no two people alike, no two brain injuries are the same. An acquired brain injury is an injury to the brain that has occurred after birth; these injuries are not a result of heredity, nor are they congenital or degenerative. There are two types of acquired brain injuries, non-traumatic and traumatic. A non-traumatic brain injury is caused by damage to the brain by internal factors, such as lack of oxygen, exposure to toxins, pressure from a tumor, and so on. A traumatic brain injury is an injury to the brain that is caused by an outside force or impact that is sudden and damaging.

Common Causes of Brain Injury

  • Stroke
  • Anoxia/hypoxia (lack of oxygen to the brain)
  • Neurotoxic poisoning (ingestion of insecticides, solvents, lead)
  • Tumors
  • Virus/infection
  • Seizures
  • Falls
  • Motor vehicle accidents
  • Struck by an object
  • Sports
  • Improvised Explosive Device (IED)
  • Assault

Brain Injury Recovery

Following a brain injury, it is imperative to receive the proper rehabilitative care. Brain injury survivors can experience an array of cognitive, physical, and emotional/behavioral challenges. These symptoms can often concur feelings of hopelessness in survivors and caregivers, but there is hope. The goal of brain injury rehabilitation is to maximize function and encourage survivors to achieve their fullest potential. Origami Brain Injury Rehabilitation Center brings together a team of experts from the following disciplines including physiatry, psychiatry, psychology, physical therapy, occupational therapy, speech-language pathology, recreational therapy, rehabilitation nursing, vocational, and more in order to tailor a care plan to the needs of each survivor. The rehabilitation journey begins with a thorough assessment to identify the individual’s exact needs and goals. At Origami, survivors and their support systems are an essential part of the interdisciplinary team and the rehabilitation journey. It is important brain injury survivors and caregivers know they are not alone on this journey. If you have a question about brain injury or if you are interested in learning more about brain injury rehabilitation, please visit our website at origamirehab.org or call us at 517-336-6060. For those looking for support, visit BIAMI's Support Group page or call them at (800) 444-6443. Origami Brain Injury Rehabilitation Center is a 501(c)(3) non-profit organization located in Lansing, Michigan. Origami provides comprehensive rehabilitation care for survivors of brain injuries and their families. Through their compassionate and innovative services, Origami creates opportunities and transforms lives.
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