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Chia Joel

on 3 July 2015

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Transcript of Cognitive-Rehabilitation

Mission Statement & Vision
We strongly believe in
service excellence
in providing
holistic care
for individuals with neurological conditions presenting cognitive and/or physical impairments to facilitate recovery to their
optimum level of functioning
with the ultimate goal of securing full or part time
gainful employment.
Referral Criteria
Stage 1: Initial Comprehensive Evaluation
Stage 2: Meet the Employer Session
1. Analyze Joseph's new role and establish new work demands in the workplace
2. Provide recommendations to the employer and Joseph.
(AOTA, 2015)
3. Identify employers expectations and job requirements
4. Advocating for Joseph’s right
5. Explanation of Joseph’s condition and deficits
6. To achieve a mutual agreement between all parties involved
7. Collaborative Goal setting

Stage 3: Pre-work Site Assessment
. To evaluate Joseph’s current & potential skills to manage job demands

2. To evaluate if the initially agreed upon work demands and expectations are realistic

3. To observe and assess for further issues or environmental modifications

4. To advocate and recommend modifications and to Joseph’s workplace and that the employer agrees to these modifications
Stage 4: Individualized Rx Plan
1. Person:
In addition to preparing Joseph to return to work by building his cognitive skills, Joseph would also be equipped with enhanced coping skills and pacing techniques.

A Cognitive-Rehabilitation
Return-to-work Program

To provide
post-acute vocational rehabilitation, on- job training, job referrals, and other employment support for individuals with neurological conditions

To conduct a
comprehensive vocational assessment

to determine an individualized treatment plans that focus on
reintroducing life skills
that are specialized to our client’s needs and recovery goals

To enable clients to become
, whether through gainful employment or volunteer work eventually leading to a
better overall quality of life

To help clients
their cognitive limitations and emotions to develop a
positive and realistic outlook for the future
28 year-old man

sustained a

moderate brain injury

following a road traffic accident.

He made

full physical recovery

but formal

neuropsychological assessment revealed poor
memory, higher executive function

impairment (planning and organizing) and shows signs of

He is married with two children and used to work as a

Human Resource Manager

Case 1: Joseph
A Return-to-Work Recovery Journey

Defined as a
systematic, functionally orientated service

therapeutic activities
that is, based on

of the patient's brain behavioral deficits.

What is cognitive rehabilitation?
(Alladi, Meena & Kaul, 2002)
Common Neurocognitive Deficits
Visuo-spatial functions
Executive functions including mental flexibility

Graduation Criteria
Key Features
(Wilkos, Brown, Slawinska, & Kucharska, 2015)
Case 1: Joseph
Joseph has indicated that he wishes to return to work
as a human resource manager, and
his employer has agreed to take him back as
long as he is able to meet certain requirements

1) Individualized Management
2) Personalized Cognitive Interventions
3) A collaborative Approach

Individualized Programme managed by an OT
Complexity and uniqueness of cognitive deficits
No two clients presents themselves in the same manner despite having the same condition
Customized RTW programmes are required to better cater to their needs and specific goals in relation to their different job interests

OT as Case Manager
The OT’s ability to assess the skill requirements of different jobs and determine the match with the patient’s present capabilities is an advantage in this type of case management.
(Egan, Savard, 2003)

2. Occupation:
Addresses the issues of productivity, safety, physical tolerances and worker behaviors
To work on Joseph’s limitations that are affecting his work performance
On-going with work hardening

Our Main Cognitive Interventions:

Reinforcing, strengthening or reestablishing previously learnt patterns of behavior

Establishing new patterns of cognitive activity through compensatory cognitive mechanisms or impaired neurological systems

Establishing new patterns of activity through external compensatory mechanisms such as personal orthoses or environmental structuring and support

Enabling persons to adapt to their cognitive disability, even though it may not be possible to directly modify or compensate for cognitive impairments, in order to improve their overall level of functioning and quality of life

(Alladi, Meena & Kaul, 2002)
Stage 4: Individualized Rx Plan
A collaborative approach:

Early contact between the employer and the injured worker

Advocating for client and employer to engage in work accommodation (Designing the plan)

Ensuring that the plan supports our client without disadvantaging co-workers and supervisors

Training employers/supervisors by including them in the RTW planning

With the client’s consent, employers and healthcare providers communicate with each other about workplace demands, as needed

(Tasmania, 2010)

(Results) Predictors of RTW:
3. Environment: (Assessed during Pre-Worksite Ax)
To identify ergonomic hazards and provide recommendations to minimize health risks and improve the ergonomics of a workstation
Stage 4: Individualized Treatment Plan
Stage 7: Supported Work Trial
client’s readiness
for work trials in job she has
indicated interest

with local companies for a 1-2 weeks work trail
Work Trial: To develop and apply
critical work skills and behaviours
learnt &
further asses
Linda’s ability to retain skills learnt and to apply them on the job

Linda will decide if this is the job she wants to take on and will then sign the contract and
be committed

Through this work trail we can also further assess Linda’s
cognitive capacities and limitations
and allow us to provide her
adequate support
she needs
Stage 8: Post-Work Site Assessment
Following from the pre worksite assessment, the
OT will head down together
with Job coach after Linda have worked for 1 week in supported employment.

The OT will
reassess all the modifications
that have been recommended and identified that
Linda has no issues
so far with his work demands and work environment
Stage 8: Graduation
After supported employment for 3months, evaluation with OT, Job Coach, employer and Linda to assess (M.E.S):

1. Return to work goals are met

2. Satisfaction level of both Linda and employer about job performance through interview and updates

3. OT’s observation of Linda’s work-related skills, based on how efficiently and appropriately he performs a work activity

* Meeting the graduation criteria of the programme→ Graduate from programme

2 Occupational Therapist
3 Therapy Assistants
2 Administrative Staff from the VWO
2 Social Workers
4 Job Placement officers/ Job Coach
Collaboration with Acute Hospitals in Singapore for the Referral process

MSF Recurrent and Capital Funds
The funding covers:
Recurrent expenses such as operating costs to deliver the services
Capital expenditure for facilities, including construction, renovation, purchase of furniture and equipment and cyclical maintenance costs
Resource Development
Resource Development
Total Cost: $126,000
Total Cost per month: $10,500
Long-Term Project Plans
To accommodate to more client types in the future:

Expansion of programme to take in more severe cognitive impaired to target a wider group of clients

To get more funding to extent our programme further to about 3 years

CAOT. (2015). Professional Development. Retrieved from Canadian Association of Occupational Therapist: http://www.caot.ca/default.asp?pageid=1185
Franche, R. L., Baril, R., Shaw, W., Nicholas, M., & Loisel, P. (2005). Workplace-based return-to-work interventions: optimizing the role of stakeholders in implementation and research. Journal of occupational rehabilitation, 15(4), 525-542.
Katz, N., Itzkovich, M., Averbuch, S., & Elazar, B. (1989). Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Battery for Brain-Injured Patients: Reliability and Validity. The American Journal of Occupational Therapy, 43(3), 184-192.
University of Illinois Board of Trustees. (2015). MOHO Products. Retrieved from Model of Human Occupation: Theory and Application: http://www.cade.uic.edu/moho/products.aspx
Alladi, S., Meena, A. K., & Kaul, S. (2002). Cognitive rehabilitation in stroke: therapy and techniques.
Hofgren, C., Esbjörnsson, E., & Sunnerhagen, K. S. (2010). Return to work after acquired brain injury: facilitators and hindrances observed in a sub-acute rehabilitation setting. Work, 36(4), 431.
Wilkos, E., Brown, T. J., Slawinska, K., & Kucharska, K. A. (2015). Social cognitive and neurocognitive deficits in inpatients with unilateral thalamic lesions - pilot study. Neuropsychiatric Disease and Treatment, 2015(11), 1031-1038. doi:http://dx.doi.org/10.2147/NDT.S78037
Tasmania, W. (2010). Injury management: making it work.
Gaber, T. A. K. (2008). Case studies in neurological rehabilitation. Cambridge university press.

Treatment plan: Progressive rehabilitation program, minimum 4 hours a day, 3-5 times a week
Bade, S. (2010). Cognitive executive functions and work: Advancing from job jeoprdy to success following brain aneurysm. Work, 36, 389-398.
Post, M. W., & De Witte, L. P. (2003). Good inter-rater reliability of the Frenchay Activities Index in stroke patients. Clinical rehabilitation, 17(5), 548-552.
Murphy, L., Chamberlain, E., Weir, J., Berry, A., Nathaniel-James, D., & Agnew, R. (2006). Effectiveness of vocational rehabilitation following acquired brain injury: preliminary evaluation of a UK specialist rehabilitation programme. Brain Injury, 20(11), 1119-1129.
Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., ... & Ashman, T. (2011). Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Archives of physical medicine and rehabilitation, 92(4), 519-530.
Stage 4: Individualized Rx Plan
Step 5: Supported Employment
Joseph went back to work at previous employment as a human resource manager for 3 months
Gradual RTW: Reduced workload with gradual increase in schedule and responsibilities (Bade, 2010)

Job Coach goes down weekly to review Joseph’s performance and provide OT Case Manager regular updates to facilitate the monitoring of his progress

At the end of the 3 months, OT will arrange for another Meet the Employer Session to decide if Joseph would like to commit to full time employment.
Step 6: Post-Work Site Assessment
Following from the pre-worksite assessment, the OT will head down together with Job coach after Joseph have worked for 1 week in supported employment.

The OT will reassess all the modifications that have been recommended and identified that Joseph has no issues so far with his work demands and work environment
Step 7: Graduation
After supported employment for 3months, evaluation with OT, Job Coach, employer and Joseph to assess (M.E.S):

1. Return to work goals are met

2. Satisfaction level of both Joseph and employer about job performance through interview and updates

3. OT’s observation of Joseph’s work-related skills, based on how efficiently and appropriately he performs a work activity

* Meeting the graduation criteria of the programme→ Graduate from programme
Case 2: Linda*
Stage 1: Initial Comprehensive Vocational Evaluation
Adapted from Gaber, T. (2008). Case studies in neurological rehabilitation. Cambridge, UK: Cambridge University Press.
(Results) Predictors of RTW:
Linda was
31 years old
when she had a
stroke as a result of a brain aneurysm
. At the time, she was working as a
production assistant
for a TV station.
She had
difficulty with balance, attention, problem-solving, and fatigue
She was unable to manage her job and had difficulties with many life skills such as doing the laundry and taking the MRT.
She currently lives with her 35 year old sister and is not married. Linda indicated she wishes to return to work.
Therefore, she was referred to us to embark on our programme
*Pseudonym. Case study based on Katsouras, Nancy. (1998). Occupational therapy and limited return to work. Outcomes that Matter: A Case Study Review, p.41
Stage 1: Initial Assessment (Evaluation)
However, after carrying out the initial vocational assessment, it was identified that she will face many challenges if she were to return back to her previous employment

Furthermore, her employment was not keen to take her back due to the need to fill up her post immediately

Therefore, the OT suggested the available alternatives and Linda was very receptive.

She expressed that she is open to exploring new job options
The OT engaged Linda in
goal setting:

1. Identifying Linda’s assets & limitations that may affect her work performance

2. Clarifying expectations from both sides (OT & Linda)

3. Realistic goal setting

4. Setting time frames for objectives and for reaching benchmark achievements along the way (Small successes)
Stage 2: Goal setting
Stage 3: Work conditioning
The OT works with Linda for:
An hour a day for six weeks

Going over therapeutic exercises, range-of-motion activities and strengthening exercises

To allow Linda to gain enough strength and balance to increase her activity tolerance
Stage 4: Job Search involving Job Coach
Job matching process to determine the best client-centered fit

Checking the local labour market/our pool of tied-up organizations for jobs that interest the client

Interest surveys, personality and aptitude assessments

Job coach will teach her interview skills, resume writing skills (Murphy et al., 2006)

After much consideration, guided by the OT and Job coach through the Job Search Process, she finally decided to try out as a
customer relations officer
Stage 5: Meet Employers Session
Using the PEO model
Stage 6: Individualized Rx plan
1. Person:
Stage 6: Individualized Rx plan
2. Occupation:
Addresses the issues of productivity, safety, physical tolerances and worker behaviors
Stage 6: Individualized Rx plan
3. Environment:
(Work hardening/ work simulation)
Interpersonal skills
Communication with clients, colleagues and in a team discussion
Work Simulation of daily task
e.g. Problem solving, decision-making skills, working in a team
Education on workplace safety and worker behaviours
e.g. Clear guidelines on the “dos and don'ts” in work. Guidelines are placed in on a wall visible from the client’s work station.

(Ergonomics/ Job accommodation)
To recommend appropriate modifications and workplace design

Educate Linda the correct workplace ergonomics
Focus on one task at a time and complete it before moving on to the next task.
Taking regular breaks from tasks that require prolonged attention.
Reminders placed in Linda’s visual field

Using the PEO model
Stage 7: Supported employment
Linda ends work trial and now begins work as a
fully committed staff
of the company

Gradual RTW:
Linda, Employer and Job Coach will have
monthly Contact sessions
facilitated by our OT for
a period of 3 months
to allow for
build-up of skills and transition
into the new job, also to
adjust and increase workload
and schedule and

(CAOT, 2015)
Coping skills
e.g. Increase work schedule by increasing no. of hours gradually over a period of 3-4 weeks.

Skills specific to Job requirements affected by impairments
e.g. Planning and Organisation skills, multitasking skills, time management skills, etc.
Interpersonal Skills
e.g. Communication with clients, colleagues and in a team discussion
(Hofgren, Esbjörnsson & Sunnerhagen, 2010)

Work simulation of daily work tasks:

e.g. Working in a team, concentrating on tasks, Physical and cognitive tolerance
Education on workplace safety and worker behaviours

Workstation Reorganisation
Change his working table to somewhere with least distractions and most convenient
Job accommodation
Graded RTW
Modified hours, duties

(CAOT, 2015)
(Franche, Baril, Shaw, Nicholas & Loisel, 2005)
Full transcript