Headway UK provides support and information to people with acquired brain injuries and their families through a network of local support groups across the UK. The organization aims to bridge the gap between medical care after brain injuries and cognitive rehabilitation services. Cognitive rehabilitation involves holistic assessment and treatment, including education about cognitive issues, goal setting, skills training, compensation strategies, and addressing emotional needs. Two case studies are presented: Ian, who had memory and attention problems treated with cognitive strategies and anxiety management, and Heather, whose frontal lobe damage caused behavioral issues treated with medication, education, counseling, and involvement in a volunteer program.

1. Cognitive Rehabilitation in
practice
Steve Shears MSc
training.manager@headway.org.uk

2. Headway UK – the brain injury association
WWW.HEADWAY.ORG.UK
Headway UK – a registered charitable organisation in the UK
supporting and providing information to people living with acquired
brain injury and their relatives.
We also provide information and training about acquired brain injury
to health and social care professionals.
We deliver this service through a network of 117 local support
groups in all four countries of the UK.
We are involved in bridging the gap between the excellent work
done by acute medicine to save people following brain injury and
cognitive rehabilitation services.

3. Aims for today
To consider aspects of assessment and
treatment of cognitive problems and how the
client’s emotional needs should be part of a
holistic assessment and treatment programme.

4. My role in Headway
I head the training services but also see people for psychotherapy
who are having problems with the psychological adjustment to their
brain injury.
I also see partners and relatives of people living with brain injury.
I have a specialised interest and training in psychosexual therapy
and I am interested in sexuality and relationships as a rehabilitation
concern following acquired brain injury (Baker, M and Shears, S 2010)
I need to modify my therapeutic approach in order to engage clients
with cognitive deficits.

5. Key brain sites and implications for
injury.

6. Key issues in neurorehab
Restoration versus Compensation.
The brain does not regenerate after damage due
to stroke or head injury.
But long term functional improvements do occur
over months or years.
Lost skills can sometimes be re-taught or
compensatory strategies can be taught to help
get round the deficit.

7. Cognitive problems – like those in our
everyday lives but more frequent?

8. Had any of these in the past week?
In the past week have you had an experience of:-
Getting to the top of the stairs (or anywhere) and have forgotten why
you went there?
Knowing that you knew the same of someone or something and
couldn’t quite retrieve it (tip of the tongue)?
Losing the thread of what you were saying when you became
distracted?
Forgetting an appointment or something else you should have
done?
Finding it hard to divide your attention between two tasks?
Following a brain injury these difficulties become more pronounced.

9. A quote
“We do not lack cognitive rehabilitative strategies following brain
injury. In the last few decades we have developed a lot of them. It is
getting patients/clients to do them that is the challenge” Rick
Parente PhD
His talk at a cognitive rehabilitation conference in Denver was
subtitled ‘stuff we tried in brain injury rehab over the past 25 years
and it worked!’
A key factor was a person-centred approach of the client seeing it as
something that solved a problem for them –therefore they might be
more motivated towards achieving their goals.
Clear goals are an important part of treatment.

10. Holistic Assessment and Treatment
It is helpful to have a through assessment, clear goals and
multidisciplinary input but the cognitive rehabilitation might not be
successful if the client’s emotional needs are not addressed
(Prigatano 2002).
This is particularly salient when some researchers have said that a
significant proportion of people living with brain injury are suffering
from depression and anxiety (Wilson et al 2009)
As cognition improves due to rehabilitation people may also become
more aware of their deficits and changes to their lives thus
increasing anxiety and depression.

11. Cognitive Rehabilitation Therapy
CRT is made up of:
1. Education about cognitive weaknesses and strengths. Education
in groups –less threatening.
2. Setting of clear goals and development of goal management
plans. (Wilson et al 2009)
3. The development of skills through direct retraining or practicing
the underlying cognitive skills – often referred to as ‘process training’
4. The use of external and internal compensatory strategies –
diaries, electronic aids and mental strategies to remember things.
5. Application of these in everyday life, and using functional tasks to
improve cognitive skills –functional activities training.
6. Input about the emotional aspects of adjustment.

12. Case 1 – Ian – Hidden Disability
Synopsis
28 year old man knocked down by a car when crossing the road.
Unconscious for three days.
Treated in hospital in an acute medical ward and required surgery
for broken bones.
Released home and treated for Post Trauma Stress by
psychological therapist.
Brain Injury element not followed up on.
Referred to me for seven week anxiety management course for
residual effects of post trauma stress.

13. Ian (Continued)
Treatment (7 Sessions)
Education and information about causes and effects of acquired brain injury.
Videoing of sessions to reinforce points discussed in sessions - due to his
attention and memory problems Ian had a copy of the sessions to review at
home.
Development of cognitive strategies to help Ian compensate for his memory
problems at work.
Anxiety management strategies to use at work.
Self monitoring sheets for Ian to use regarding his anger management.
Counselling for the emotional adjustment issues related to his awareness
that he had a brain injury.
Referral to neuropsychology and neurology.

14. Case 2 - Heather
Synopsis
Sub-arachnoid haemorrhage
Damage to frontal lobe and hypothalamus areas.
Alteration in executive function and hypersexuality with
behavioural problems and risk-taking behaviours due to
poor insight and impulse control.

15. Heather (Continued)
Treatment (Over a five year period)
Medication to lower libido and hormone replacement.
Education for Heather about her brain injury.
Behavioural therapy aimed at reducing incidences of inappropriate behaviour.
Supervision
Whole family/friendship networks educated to give consistent response to Heather’s
behaviour. Husband was very involved in co-ordinating this.
Counselling for Heather to deal with her emotional adjustment to the loss of her pre-
injury self and status.
Social Services have now involved Heather in a volunteer training programme and
this is meeting her vocational needs.
Her insight and behaviour are such improved now.

16. Conclusion
Holistic assessment and treatment incorporating
cognitive rehabilitation therapy and counselling
support can lead to better outcomes for clients
following acquired brain injuries.

17. References
Baker, M and Shears, S (2010) Sexuality training for health and social care
professionals working with people with an acquired brain injury. Social Care
and Neurodisability • Volume 1 Issue 3 • November 2010 © Pier
Professional Ltd
Parente, R (2007) Society of Cognitive Rehabilitation Conference,
Westminster, Denver, Colorado
Powell, T (2004) Head Injury – A Practical Guide, Speechmark.
What Do Patients Need Several Years After Brain Injury?(2002) Prigatano,
G.P. Barrow Quarterly. Vol18 No2
Wilson, BA, Gracey, Evans, J, Bateman, A. (2009). Neuropsychological
Rehabilitation: Theory, Therapy and Outcome. Cambridge University Press.

18. Web references
http://www.dh.gov.uk/en/Publicationsandstatistic
s/Publications/PublicationsPolicyAndGuidance/D
H_4105361 (2005 (NSF Long Term Conditions-
UK Department of Health Website)

19. Your views or questions to :
Training.manager@headway.org.uk
(+44)115 9240800