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Introduction

Individuals who have acquired a traumatic brain injury (TBI) will often exhibit difficulties in social communication, concentration, low awareness, and executive functions such as organizing and problem solving (Pendleton, H. and Schultz-Krohn, W. 2013). For people with borderline personality disorder, such as Brandon Marshall, will also demonstrate characteristics of decreased self awareness and insight. Additionally, his cumulative injuries as a football player have consequently hindered his executive functioning skills.

Cognitive interventions used by occupational therapists for high-level cognitive impairments include repeatedly practicing the sequence of a task, writing out the steps of a task, and sorting objects in the order in which the activity is carried out. (Pendleton, H. and Schultz-Krohn, W. 2013)

Theory

Occupational therapists use a cognitive retraining approach as a remedial approach that focuses on retraining individuals to overcome their cognitive deficits. Averbuch and Katz developed the cognitive retraining approach. A common characteristic of this approach is repetition, as it facilitates new ways of solving problems and learning new skills. Areas of training include memory retraining, organizational skills, reasoning, and decision making. As the cognitive abilities in these areas get better, the main objective is that the skills will become generalized and transferable to various situations in life. (Krajnik, 2015)

Evidence

Kontos et al., developed a cohort study to determine whether post-traumatic migraine (PTM) after a sport-related concussion during the first week after injury predicts cognitive impairment and symptoms in overall recovery time. After looking at 138 male high school football players who had a sport-related concussion, they classified the students in three groups: those with PTM, those with a headache but no other PTM symptoms, and those with no headache. Using an Immediate Post-concussion Assessment and Cognitive Test (ImPACT) to assess cognitive performance and symptoms at baseline and post injury, recovery time data was collected. They found the PTM group performed worse on verbal memory, visual memory, and reaction time. This concluded that PTM is associated with cognitive impairments after a sport-related concussion (Kontos et al., 2013).

According to Diya & Keshav, traumatic brain injury is often associated with cognitive impairments. Their single case experimental design had a twenty-five-year-old male with a left temporal hemorrhagic contusion with cerebral edema. He underwent two months of a cognitive retraining program to address executive functions. They used a pre- and post- assessment to see changes in his responses. Results concluded improvements in cognitive functioning and occupational functioning with symptom reduction following post traumatic brain injury (Diya & Keshav, 2012).

Case Study

Brandon Marshall is an American football wide receiver for the New York Giants (“Brandon Marshall”, 2017). He is 33 years old and was diagnosed in 2010 with Borderline Personality Disorder. Marshall has stated that he always knew that there was something wrong but he did not know what it was or that he could even be helped. Additionally, throughout his football career, he has sustained several head concussions, affecting his higher level cognitive processing. Presently, he expressed he is having difficulty with planning and organizing tasks within his career.

Intervention Plan

Problem Statement

Brandon has difficulties with planning and organization in work secondary to decreased higher cognitive processing skills.

Long Term Goals

1. Brandon will independently monitor his weekly exercise plan in which he previously developed with a daily checklist for participation in work within four weeks.
2. Brandon will independently exhibit improved executive functioning through consistent utilization of self-talk techniques during the last four sessions of therapy to participate in work in four weeks.

Short Term Goals

1. Brandon will identify five problem areas to improve upon in his exercise routine to participate in work using three verbal cues within one week.
2. Brandon will independently choose ⅗ exercise activities independently to address the problem areas he previously identified for participation in work in two weeks.
3. Brandon will independently write out and organize an exercise plan for a 7-day week in order to participate in work within three weeks.

Intervention Format

Individual

Setting

Brandon will meet with the occupational therapist individually at the therapy center for 30 minutes, twice a week.

Supplies

A video of Brandon from a football game in which he performed well in.

Agenda

• Meet Brandon & develop rapport (5 min)
• Assess Brandon using the Montreal Cognitive Assessment (MoCA) (10 min)
• Discuss the results of the assessment with Brandon (5 min)
• Engage in cognitive retraining for improved planning and organization (15 minutes)
  • Brandon will identify problem areas within his exercise routine he is struggling with during work
• Provide a summary of the session (5 min)

Documentation

S: “Since my recent concussion, I’ve been feeling very confused lately when trying to complete my practice routine. I just feel disorganized with things I need to be doing in preparation for the big games.” Client reports he is not aware of his problem areas for his exercise routine.

O: Client participated in a 30-minute session focusing on cognitive retraining. Client first completed the Montreal Cognitive Assessment and then identified 5 problems that he needs to address in his exercise routine in order to better prepare himself for games. Client identified his problem areas as his 200-meter sprint times, 400-meter split times, poor agility, poor balance, and decreased grip strength.

A: Assessment results from the Montreal Cognitive Assessment indicated mild cognitive dysfunction within the area of executive functioning. Client also demonstrated confusion and indecisive thinking during his treatment session. Client required 11 verbal cues and 6 redirections in order to attend to identifying his limitations in his exercise routine.

P: Brandon will continue to attend occupational therapy twice a week for 30 minutes to improve executive functioning during work performance. During the next session, Brandon will choose exercise activities to address his problem areas for work participation.

References

Cognitive Retraining. (n.d.). Retrieved March 9, 2015, from http://www.minddisorders.com/Br-Del/Cognitive-retraining.html

Diya , N., & Keshav, K. (april 2012). Cognitive retaining in traumatic brain injury. Neuropsychological Trends ,11, 65-74. Retrieved February 9, 2018, from https://search-proquest-com.ezproxy.fiu.edu/psycinfo/docview/1025846800/DF6C4BEF60A34770PQ/1?accountid=10901.

Kontos, A. P., Elbin, R., Lau, B., Simensky, S., Freund, B., French, J., & Collins, M. W. (2013). Posttraumatic Migraine as a Predictor of Recovery and Cognitive Impairment After Sport-Related Concussion. The American Journal of Sports Medicine,41(7), 1497-1504. doi:10.1177/0363546513488751

Krajnik, S. (2015). Week 2: Neurological impairments & approaches in neuro OT practice [PowerPoint slides].

Pendleton, H., & Schultz-Krohn, W. (2011). Pedretti’s occupational therapy for physical dysfunction (7th ed.). St. Louis: Mosby Elseiver.

Pendleton, H. and Schultz-Krohn, W. (2013). Work Evaluation and Work Programs, Pedretti’s occupational therapy. St. Louis, Missouri: Elsevier/Mosby.