NEUROPSYCHOLOGIST WITH MILD BRAIN INJURY:

WHEN PATIENT IS ALSO DOCTOR

Michael F. Martelli, Ph.D

In this article, a neuropsychologist examines early and late post-concussive symptoms. The unique findings of a rehabilitation neuropsychologist who specializes in teaching compensatory cognitive, emotional and behavioral coping strategies who sustained a mild, complicated Acquired Brain Injury (ABI) are presented. Issues relating to identification of symptoms via skills inventory, the process of making attributions about many symptoms (e.g., age vs. stress vs. post-concussive vs. pain), the role of information/ preparation by profession, skills repertoire, expectancy and vulnerability/ resilience factors are explored. Finally, the conceptualization of ABI as disrupting essential habits and the application of a habit retraining restorative model is presented, along with a suggestive outline of some of the specific compensatory strategies that were employed to reestablish necessary habits to continue employment, without interruption.

Patient

• 38 year old, white male, rehabilitation neuropsychologist
• Director of a hospital psychology service where he was also senior clinician with full clinical work load

Accident Details:

• 3:00pm, Sunday, April 24, 1994, while traveling to work.
• Patient vehicle (small Isuzu Pickup) entered secondary highway 100 feet from home driveway and was struck on passengers side by vision obscured vehicle traveling 55 mph (per police report; skids suggest faster)
• Patient vehicle entered 250 ft. sideways skid, sliding across highway divider, through gully on side of road, stopping in a large juniper tree/bush.
• Seatbelt-less patient slid across bench seat and struck right posterior skull and neck against door chassis, door
• Patient vehicle was totaled, while other vehicle incurred 10K in damage (Jeep Cherokee)

Emergency Medical Assessment and Treatment:

• Minimal or no LOC, per witness reports
• Ambulance transport to ER
• Contusion to right parietal area of scalp, requiring 20 stitches.
• Significant blood loss noted, with consideration of transfusion, association with low potassium.
• PTA noted. GCS of 15 noted at 3 hours post injury.
• Diagnosis: Traumatic Brain Injury, Grade II.
• CT scan conducted, showing small petechial hemorrhage at coup site requiring monitoring, surgery preparation protocol implementation (including no food).
• Admission to Neuro ICU.
• PTA = 8.5 hours (1 slice of CT machine memory, color verified, is only semblance of recall). First post traumatic memory is 11:30pm, with fairly clear demarcation (i.e., recall for time on the clock on wall across from bed, when friend noted: "okay, you are finally remembering...I was terrified...").
• Retrograde amnesia of approximately 5-10 seconds, with less certain demarcation.
• Potassium IV administered, after 9 hours.
• 2nd CT, 4/25, showed no progression (resolution?) of bleed.
• Transferred from Neuro ICU to Neuro unit, on afternoon, 4/25.
• 3rd CT also clean on April 26th,
• Patient discharged in early afternoon. Notably, no formal d/c information was given, although an intern or resident did make referential comment ("You're a neuropsychologist, so you know (discharge instructions)...if you need anything, just call Dr. X).
• Discharge Diagnosis: Mild TBI (Complicated)

Litigation Status:

• None, although insurance requested patient pay bill, given large deductible (2K). PTA at time of accident led Policeman, and patient, to believe other vehicle report of patient responsibility. At hearing, it was determined that other driving was speeding and passing another vehicle from improper lane and that patient was not responsible. However, no legal action was taken against other driver.

Initial subjective responses, recollections:

• Ontologic Panic: "Oh My God, not my brain. How will I be different...Will I be able to work?"; "Let me out of here to test myself."
• Self Assessment Efforts:
• Memory: verification of events, length of PTA, etc.
• General : Information processing and Efficiency
• Specific: Right parietal lobe (Stereognosis. Finger agnosia, finger tip # perception, awareness)
• Results: Thank God, but what if I've missed something.
• Reactive Hospital Behavior (Acute distress and volitional rebellion against helpless patient role):
• Eating restriction and perceptions of hypoglycemic distress: initial negotiation, subsequent complaining, whining, begging, and more complaining ("Please, I would rather be suctioned if I needed surgery versus starve to death")
• Potassium injection pain: leg banging, which broke bed rail (resulting in K d/c). Electrolytes did improve.
• Restrictions re: phone calling in early am and loud repeated protests and notable distress, indignation, muted anger.
• Nurse expressed interpretation: "Your behavior is perseverative, consistent with brain injury...you should know that, you are a neuropsychologist...you're not acting like one")
• First walking effort on 4/25 at 2:15am was aborted due to nausea, incoordination, imbalance
• Second walking effort at 8:00am or so revealed requirement for very deliberate effort, compensation, but quickly improving balance
• First look in mirror: "They shaved 1/3 of my head....I look brain injured and freakish...why did they shave 1/3 of my head for this little cut...how demeaning!"
• First phone calls on 4/25/98: Canceled patients, contacted two neuropsychologist friends.
• Discharged, 8/26 in am, after attending MD got agreement from patient father to spend rest of week in residence

First Discharge Activities:

• Purchased car ignition and, with slight help from father (primarily for upside down work, which produced significant vertigo) repaired back up vehicle on 4/26.
• Drove on 4/26/98 without compromise. Noticed increased fatigue and mild, intermittent dizziness.
• Attended to insurance details, etc., on 4/27
• Visited work on 4/27 and told "war stories". CEO directed a return home & requested MD release before return to work.
• MD Visit 4/28.
• Appropriate attentiveness was greatly appreciated
• Neuropsychological evaluation 4/29:
• Too much attention to litigation issues Vs. clinical issues, clinical interview
• All testing was completed by a technician
• Results: possible subtle findings on Stroop Color Word Test, but generally clean
• Impression: "Boy, I wonder how much worse it must feel (i.e., like a technical procedure) for patients who aren't neuropsychologists and friends of the examiner?"
• Returned to work to straighten up, visit, tell ABI story, and obtain clearance to return to work.
• MD (Dr. Zasler) report received by CEO. Return to work cleared for 1/2 days.
• Returned to work for 1/2 days after weekend, but cheated
• 1/2 days were really 3/4 days, blending into full time after one week, quickly bending into usual 60 hours over next few weeks.

Early Symptom Course

• Sensitivity to noise
• Sensitivity to sudden, accelerated movement and exercise (anxiety, fear of re-bleed)
• Auditory attention inefficiency noted on retrieving phone numbers from voice mail (for moderately fast speakers)
• Significant neck pain, superimposed on history of neck injuries and intermittent neck pain
• FATIGUE: 5:00 pm brought on near zombie state involving subjective perception of psychomotor retardation and somnambulism, even if standing
• Subjective Hypoglycemia, requiring frequent snacks to prevent dizziness, nausea, cognitive disorganization
• Intermittent dizziness, nausea, as noted above, and in response to physical exercise
• No Irritability, except for compensated response to noise (high shrilled voices, multiple conversations)
• Subjectively reduced eyesight and increased eye fatigue

Early Symptom Course and Late Symptoms (With Compensation)

• Sensitivity to Noise faded from noticeable after 2 months
• Nausea faded, except during exercise, after 2 months.
• Exercise (high impact aerobics) produced extreme nausea, fatigue, at 3 months.
• Returned to tolerance of high exertion, extended exercise at 4-6 months, without any changes, except for some decreased stamina attributed mostly to inactivity.
• Subjective hypoglycemic symptoms faded after 3-5 months.
• Some comments from other colleagues suggested possible decreases (i.e., improvement) versus premorbid irritability, hypomanic tendencies.
• Auditory attention inefficiency noted on retrieving phone numbers from voice mail (for moderately fast speakers).
• Neck pain mostly resolved, although increased pain and some "locking" noted with stress, cold weather, cold drafts.
• Auditory attention inefficiency (e.g., retrieving phone numbers from voice mail for moderately fast speakers; some inversion of inner digits) has never fully remitted, and remains somewhat noticeable with fatigue.
• At 2 years, morning routine remained significantly protracted (i.e., rising, getting dressed, leaving for work) until, while trying to entice a patient with related problems to employ a Task Analysis, the psychologist patient constructed one for himself. Symptom resolution was almost immediate.
• 4.5 years Post: Approached at Gym by attractive woman who seemed to know this psychologist fairly well. This unhappily single neuropsychologist did not recognize her beyond familiarity, even though he could not fathom not recognizing such an attractive woman. This initially lead to acute anxiety ("Wow, was this something that was wiped out by the brain injury...am I missing a piece...is there anything else I am missing?"). However, this attribution changed:
• 15 min after her departure, full recollection occurred: Patient had dated the nurse for 4 months. He really liked her and always regretted her discontinuing the relationship due to religious differences.
• Notably, she was now 10 years older and had not aged well compared to her previous appearance and looked quite dissimilar: completely different hair color (sandy vs. chestnut) and hair style, different teeth, etc.

Identification of symptoms via skills INVENTORY:

The process of making attributions about many symptoms, after an accident and life disruption causes an unexpected and unusual attention to current status, is complicated. When one looks in the mirror, one expects to see a 25 year old. Age versus stress versus post-concussive symptoms, versus pain, represent some of the attributional options.

The following require inferential reasoning with regard to attribution, and remains speculative.

• Eyesight: TBI or age, or combination
• Notably, patient had used eye exam documenting declining eyesight to try to beat a traffic ticket just 2 years earlier.
• Fatigue
• In Grad School, patient had long Wednesdays (when young and healthy as a horse) and made attributions at that time that long Wednesdays resulted in unusually poor efficiency on Thursdays (e.g., clinic procedure mistakes, etc.)
• As and Undergrad, took naps after dinner for 1/3 of 4 years and perceived that this helped with motivation, paper writing, study efficiency.
• Decreased activity in this somewhat hypomanically inclined individual had historically been associated with fatigue
• Neck pain required extra effort to concentrate, which is probably tiring
• Brother reminded patient that months before the injury, he had complained of getting old, tiring more easily, and complaining that age and job stress were stealing his energy
• New job added increased duties, and patient is historically bad at delegating responsibility

Compensatory Coping

• Education, information and accurate expectancy (by profession, with some additional review)
• 5 Commandments of Rehabilitation were authored by the patient for use with his patients, and these were employed for himself
• Reattribution of symptoms was performed, with Pacing and De-catastrophizing Self Talk
• Active Coping was employed
• Task Analyses were employed for a couple of residual problems
• Graduated exposure, Attention Redirection and "Manual Pilot" Pacing and Self-Instructional strategies were employed

Resilience Factors: Positive Prognostic Indicators

• Young
• Bright
• Athletically competent
• History of overcoming life stress / challenges
• Good academic achievement
• Good occupational achievement, adaptation
• Very supportive colleagues and support staff at work
• Good TBI Vulnerability and Vulnerability to Disability Scores (retrospective analysis)

Positive Effects

• Cementing of a conceptualization of ABI as disrupting essential habits that underlie everyday efficiency
• Formulation of ABI Rehab as Habit Retraining (HABIT RETRAINING MODEL)
• Integration of a model for employing specifically derived compensatory strategies, along with an attitudinal shaping component.
• Neuropsychologist was able to employ effective compensatory strategies to reestablish necessary habits, utilizing the strategies taught to patients on himself

Outcome

• Patient-doctor continued employment as a rehabilitation neuropsychologist and service director, without interruption and was able to employ a couple effective compensatory strategies to reestablish preinjury efficiency.
• Two years later, patient-doctor employed a Task Analysis to restore preinjury morning routine and cut time by 50% (or to preinjury dressing time)
• In the next four years, patient - doctor was: (a) selected the only male "Employee of the Year" for "tireless...unselfish ...patient centered" treatment intervention provision (only to subsequently be castigated for same behaviors when requirement for poorer quality, shorter, decreased quality treatment, and decreased financial aid became standards of treatment); (b) accepted, a national training position with a disability evaluation certifying organization; (c) completed numerous journal articles and book chapters and his first book; (d) nominated to the board of the state Brain Injury Association; (e) joined an internationally renowned brain injury rehab physician in private practice, doubling his publications and talks in his first year.

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Martelli, M.F. (1998). Options for Improved Energy / Decreased Fatigue / Improved Sleep HeadsUp: RSS Newsletter, Vol. 1, No. 9 (Dec.).

OPTIONS FOR IMPROVED ENERGY/

DECREASED FATIGUE

M. F. Martelli, Ph.D.

• 1) Psychostimulants (e.g., Ritalin, Amphetamine)
• 2) Medications with Slight Energizing Effects: Amantadine (Anti-viral and Anti-Parkinsonian medication) And Also Energizing Antidepressants (E.G., Prozac) And some Sympathomimetics (E.G., Ephedrine Sulfate, Caffeine)
• 3) Nutrient/Herbal/Homeopathic Energizers (Ginseng, Chromium, Royal Jelly, Gigko Biloba, Octasonal, Brewers Yeast, Coco Beans, Coffee, B-6Drops,Ginkgo Bilokba, Etc.)
• 4) Activity Programs (Activity Routine, Exercise Regimen, Behavioral Activity Programs, etc.)
• 5) Energy Conservation (Task Analyses, Routines, And Paced Activity Planning for Re- Establishing Automatic Efficiency Routines; Power Relaxation Naps/Breaks For Fatigue Prevention/ Rejuvenation)
• 6) Cognitive Re-Programming - Re-Labeling and Re-interpreting with Re-programming to: A) Replace Inactivity with Activity and Acitivating Responses B) Improving Emotional Reactions And Problem Solving to Decrease Stress, Conflicts And Other Energy Draining Situations
• 7) Sleep Enhancement -

STANDARD RECOMMENDATIONS FOR

IMPROVED SLEEP

M. F. Martelli, Ph.D.

• 1. Bed Is For Sleeping Only, so don't get into bed until ready to sleep & do nothing else while in bed). Reading is the only exception, and only if it eventually makes you drowsy!)
• 2. NEVER WATCH TV IN BED. See #1.
• 3. No Daytime Naps. No naps after 2:00pm EVER, PERIOD (Consider Relaxation!).
• 4. Get Out of Bed If You Can't Sleep rather than worry or toss & turn.
• 5. Go to Bed the Same Time Every Night. If you can't sleep, get out of bed (See #4)
• 6. No Caffeine or Alcohol or Liquids before bed (except warm milk, cocoa).

OPTIONAL ADDITIONS (5-HT Loading)

• 7. Try High Carbohydrate-Low Protein Dinners & Evening Snacks. Eat Spaghetti, Pizza, Fruits, starchy carbohydrate foods for dinner & Avoid Corn & Corn Snacks At Dinner & in the evening
• 8. Try Warm milk, Hot Cocoa, Bananas, as Evening Snacks
• 9. Try an Individualized Relaxation Tape.
• 10. Try Hot Baths Before Retiring.
• 11. If you awaken in the middle of the night, try getting out of bed, making some warm milk or hot cocoa & eating a banana and/or fruit yogurt. Try reading for a while & then return to bed after an hour or so, or when you become more drowsy. Consider performing a boring, monotonous task while awake to help make you drowsy.

OTHER POSSIBLE FACILITATORS

• 12) Try coffee 20 minutes before retiring to see if it has a paradoxical (opposite) effect.
• 13) Try herbal (decaffeinated) tea 15 minutes before retiring.
• 14) Take a Yoga Course and Practice.
• 15) Buy a Massage book and use it with your spouse or partner.
• 16) Try Non-Aerobic exercise 30 minutes before retiring.
• 17) Try Aerobic exercise 30 minutes before retiring.
• 18) Take one or two deep relaxation breaks (using tape for 20 minutes) during the day.
• 19) For members of Couples: Massage with Affectionate, "Touchy" Sensuality (for relaxation & not for orgasm).
• 20) Or, #19 for complete fulfillment
• 21) Try all of above and combine those that seem helpful.

OR, try all of them in different combinations to try to find a helpful combination.

FINAL OPTION:

• 22) If nothing seems to work for a given period, forget sleep, don't worry about it, get up immediately & do something that needs to be done & feel good about using your time wisely.

Addendum: Boredom is an age old remedy for sleep. Thoughts which alert us (e.g., things we forgot, desirous wishes, etc.) interfere with sleep. Try thinking only boring thoughts. Try to eliminate interesting or alerting or anxiety evoking thoughts. One way to do this if thoughts are especially difficult to stop (e.g., by thought chopping them) is to transform them by controlling your images & thoughts to make them boring. For example, if you are thinking about an upcoming day or events or person, make it or them boring experiences (e.g., the day is rainy and everyone is boring; the person is monotonous and says or does nothing worth paying attention to, etc.

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Martelli, M.F. (1998). Task Analyses: The Foundation of Rehabilitation Strategies. HeadsUp: RSS Newsletter, Vol. 1, No. 6 (Sept).

Task Analyses

By Mike Martelli, Ph.D.

Concussion Care Centre of Virginia (CubeV)

Task Analysis involves breaking any task or chore or complex procedure into single, logically sequenced steps & recording the steps in a Checklist. The checklist allows checking off each step as it is completed. Task analyses always make task initiation, completion & follow through much easier. Performing a Task Analysis and generating a checklist can greatly improve ability to perform tasks in persons with limitations in memory, attention, energy, initiative, ability to sustain performance, organization, or almost any other difficulty.

Task Analysis Checklists are also extremely useful in minimizing fatigue by reducing the demand for, and energy consumed by reasoning and problem solving associated with planning, organizing & having to recall, make decisions & prioritize appropriate steps and sequences for a task. Task analyses are useful for both basic and complex behaviors. Most importantly, Task Analyses allow re-establishing the efficient routines that make up normal everyday human behavior and activity. When the procedures assisted by Task Analyses are repeated consistently, they eventually become automatic [habits] and become as natural as tying a shoe.

The ingredients for rebuilding these automatic habits are the 3 P's: Plan, Practice, Promotional Attitude. The result is rehabilitation, or removing obstacles to independence.

Task Analysis Samples

Single Doctor

Chores CheatList

BATHROOM

• Dust around the Mirror and Light and Window, including the tops of the light and mirrors and window sills.
• Dust, with a damp cloth, around the windowsills, on the front of the blinds and the back (reverse sides by adjusting slats up and down), and along the tile division.

• Wipe down the bathtub walls, going to the ceiling.
• Use cleanser and a brush to quickly wipe grime in the tub, and scum stains on the wall.
• Use soapy brush to quickly wash and rinse the inside shower curtain.
• With a soapy disinfectant, clean the toilet top, seat, behind the seat, and under the seat, along the walls to the floor
• Fold all tiles neatly on the tile racks

• Sweep the floor, including behind the toilet.
• Take out the rug and shake it off of the porch vigorously to remove dirt and dust.
• Remove and empty the garbage can.
• Mop the floor, using ammonia or Clorox and be sure to get behind the toilet.
• Use a rag to get the floor behind the toilet. Be sure to get in all the nooks and crannies along the edges of the floor, near the tub, etc.

• Dust Furniture, including all shelves
• Use broom/duster to dust along all baseboards, window sills, ceiling molding & fireplace mantle
• Sweep and Vacuum Under Rugs
• Sweep and Vacuum Floors
• Vacuum the couch, love seat, and chair

• Empty Trash Can
• Clean Top of Refrigerator and Microwave (Wet Soapy Cloth)
• Clean Inside Refrigerator and Microwave
• Wash Any Dishes and Clean Sink with Cleanser
• Clean Sink and Surrounding Countertop
• Sweep, and then Mop Floor

BEDROOM

• Dust dresser tops, around doors and windows, and along baseboard and ceiling molding

• 9:00am Saturday: Take Clothes to Dry Cleaners before 10:am
• 5:00pm Saturday: Pick up clothes from Dry Cleaners and Arrange in closet
• 10:00am Sunday: Launder socks, underwear, bathroom towels, bed sheets, etc.
• 11:00am Sunday: Use Dryer & Fold & replace clothes when done. Hang Dry other clothes
• 11:20am Sunday: Steam mist to refresh any pants, shirts in need
• Sunday 9:00pm: Fold, hang, put away dry clothes

TA Samples: Single Tasks

Weekly Shopping Checklist

• MILK
• PAPER PLATES/CUPS
• HAND LOTION
• CHEESE
• NAPKINS
• CHAP STICK
• BUTTER
• PAPER TOWELS
• SHAMPOO
• EGGS
• PLASTIC WRAP
• AFTER SHAVE
• FRUIT
• TRASH BAGS

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Martelli, M.F. (1999). Fighting Fatigue in Chronic Progressive Disorders. HeadsUp: RSS Newsletter, Vol. 2, No. 7 (Oct.).

Fighting Fatigue in

Chronic Progressive Disorders

by Mike Martelli, Ph.D.

Developmental and Reactive Stresses

For persons with progressive diseases, including, for example, Parkinsons, Multiple Sclerosis, some forms of stroke, and cases of aging for many persons with brain injury, declines in health status represent a major and continuing stress that places major demands on an individual's coping resources. These stresses result from both the declines in functional abilities themselves, as well as the consequences of these declines.

• Generalized Declines in Control & Coping Resources
• Declines in Physical Ability
• Declines in Activity
• Declines in Independence
• Decreasea in Self-Esteem & Self-Confidence& Sense of Purpose secondary to decreased involvement in activities & pursuits that allow fulfillment of needs to feel useful, productive & worthwhile
• Declines in number of Friends & Social Outlets & enjoyments
• Decreases in Cognitive Abilities
• Declines in Energy & Endurance (i.e., Increasing Fatigue)

• Developmental Factors that Increase Functional Decline
• Fatigue related decreases in physical, cognitive, emotional & social functioning
• Cognitive & Social Understimulation related increases in cognitive deficits, rustiness, atrophy, depression, etc.
• Depression related reductions in physical, cognitive & social functioning, and motivation
• Misunderstanding of symptoms by others (e.g., laziness, selective memory, manipulation, etc.)
• Beating-up on Self (Guilt, Frustration, Anger --> SelfAbuse)
• Learned Helplessness (i.e., difficulty making continued effort given past failures/expectation of future failures / belief that efforts will not work / over-reliance on others /external help)

Interventions For Decreased Initiation/Endurance/Energy (i.e., fatigue), Decreased Physical Capacity, Depression, Declines in Cognition & Problem Solving & Socialization

However, compensatory coping is a means of devising new strategies to get around the resulting obstacles

• Use Compensatory Strategies as Equalizers: (see self-control procedures)
• Patience, Persistence, Coaxing and Self-Cuing of memories and efforts (promotes exercise & adaptation vs atrophy); successive approximations (i.e., baby steps and graduated successes).
• Self Pacing & Activity Planning to control fatigue
  • Internal & External Attention, Memory & Organization Strategies
  • Internal Aids (e.g., "Who, what, when, where & why?"; "Three-peat", "Bottom Line"or "One Thing at a Time"etc.)
    • External Aids (e.g., well designed memory log, outline strategies; alarm watch; etc.)

• Task Analyses to Counter Fatigue & Decreases in Organization & Energy (and memory, etc.): breaking a task into single, logically sequenced steps as a checklist that allows checking off when completed, always makes the task easier
• Assertiveness:: educating others; requesting accommodations (e.g., extra time, breaks, etc.); expressing thoughts, desires. Set incremental, step-wise goals, build self up for what can be accomplished despite obstacles, and celebrate each tiny step of progress (Nurse it, don't curse it; build yourself up instead of beating yourself up)
• Adjust Standards & Expectancies to Fit Limitations (make accurate comparisons vs inaccurate ones to healthy others, premorbid self)
• Set Modest, Incremental Goals to Allow Control & Minimize Interference Caused by Symptoms
• Employ Accurate Self-Expectancy, Self-Monitoring & Self-Evaluation and, finally
• Appropriately Self-Reinforce for Accompishment Despite Odds, Obstacles
• Identify & Engage in alternative activities that allow feeling worthwhile & useful (including social activities & involvements)
• Dispute Myths:
• "Why me...? (vs "What contract did I sign that said this would never happen to me?")
• "The Grass is always greener"
• Use "5 Commandments of Rehab", "Caregiver Rules", "Rules of Conflict", "Ideas to Help You Function" & Other Self-Help Tools, for patient, family, therapists.

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Note: Strategies referred to in this article have appeared in previous versions of Heads Up and are also included as links on this website (Villa Martelli Iternet Disability Resources), under the "Useful Rehab Model and Methodology" heading links. Email the author ( mikefm@erols.com) if you did not easily find copies.

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