guidelines for evaluation

 

 

Survivors, family members and professionals are painfully aware that the most disabling consequences of brain injury are usually cognitive and behavioural deficits. Developing techniques which lessen the impact of those deficits on daily life is a major emphasis of most treatment programs. Most rehabilitation facilities use computers in their brain injury programs although the degree to which such tools are effectively used varies widely. When used properly, computers can be effective rehabilitation tools because they:

  • are cost effective

  • increase self-esteem

  • provide repeated trials for minimal cost

  • help prepare for employment

  • may unobtrusively record data for analysis

  • provide leisure activity

  • decrease supervision needs

  • provide ways for injured individuals to interact with their peers

Some families view computers as miracle workers and are disappointed when instant recovery doesn't follow from the purchase of a computer. Those who plan to use computers must be willing to invest time and effort learning to select and operate equipment and programs: at least minimal computer literacy is essential to use computers effectively in brain injury rehabilitation. Most family members and many survivors are capable of learning to use computers with minimal training if appropriate software and hardware is available.

 

Who can use computers:

Computers are not appropriate for all individuals who have sustained brain injuries. Appropriate individuals include those who have enough:

  • behaviour control to prevent damage to equipment and selves

  • visual acuity to see the screen or specialized adaptive hardware such as screen readers

  • physical control to enter responses: adaptive hardware such as alternative input devices, decelerator cards, voice synthesizers, or screen enlargers may be required to allow some clients to access computers.

Patients responses to using computers are usually quite positive. Computers may provide their first opportunity to work independently since their injuries. Many are able to attend to tasks for longer periods of time when presented via computer, perhaps because of the novelty effect.  They report feeling the computer is less critical of poor performance and prefer to avoid failing yet one more time in an interpersonal situation where they are judged and found lacking. The argumentative client who disputes every statement made by the therapist or a family member/caregiver can frequently work more efficiently on the computer since computers don't respond to such challenges.  

 

Why use computers:

The nature and extent of the client's assets and deficits plays a critical role in determining appropriateness of computer usage for a given individual. Obviously, computers cannot remediate all deficits following brain injury but they can address the following:

attention/concentration impulsivity distractibility
cognitive endurance thinking/performance speed eye-hand coordination
learning/memory visual tracking/scanning planning/organization
quality control/self-monitoring problem-solving sequencing
spatial analysis/synthesis reasoning/abstraction inattention/neglect

 

 

When is the best time to use computers:

There appears to be no specific post-injury time when computer usage is maximally effective. In general, the earlier rehabilitation starts, the less chance there is for the individual to develop maladaptive behaviours or compensatory strategies which do not work. Individuals can improve skills through computer use as long as 20 years post-injury.  Individuals who have limited cognitive endurance are able to use computers for brief periods of time over the course of the day in contrast to the traditional 30 or 60 minute therapy session.

Where can computers be used:

Although many individuals begin using computers as part of an inpatient or outpatient rehabilitation program, computers can easily be used in other settings. Individuals can use computers in private, group and nursing homes as well as schools/colleges and vocational rehabilitation offices. Many public libraries have installed computers with access to the public and staff who are willing to teach basic computer literacy to customers. Computers are particularly appropriate tools for use by clients in remote locations where few rehabilitation services are available and transportation logistics are prohibitive.

Selecting Software:

Given the thousands of computer programs which exist, some guidelines may help in selecting appropriate software. Ultimately, however, trial and error may be the best judge of what will work and you must be willing to admit the selection was wrong for that client at that time if that is the case.

Hardware requirements:

Equipment required to run the program:  computer type (e.g. PC or Mac), memory and drive space required, required monitor display quality, printer compatibility, input devices, etc.). It is always recommended that, given the opportunity, you select software before selecting hardware. Even the best computer is not useful if you can't find appropriate programs to run on it (unless you plan to write your own programs, that is.) In my experience, rehabilitation software for Macintosh computers is hard to find.

Programs: 

Single programs like Solitaire only do one thing.  While you might collect 10-20 programs which work well, getting the user to select each of the programs might be problematic.  It's usually better to purchase a compilation of programs, designed specifically for the purpose, where, once the user selects the program, there are multiple programs or program options available.

Feedback: 

Many programs which are appropriate for a given survivor may be obviously written for young children: most adults do not respond well to Kermit congratulating them on a correct answer; in fact, they may be highly insulted. However some feedback both auditory and visual is important.

Method of recording progress:

A form of recording progress over time is highly useful, indeed  in some cases critical, in analyzing ongoing performance and ability.

Response requirements:

It is important that the software has the ability to record the users  responses., e.g. mouse, keyboard, joystick, unique key combinations, etc.

User friendliness:

The ease of program operation; ease of adjustment to meet special needs and performance, plus informative help screens.

Technical support:

The availability of knowledgeable staff to answer questions regarding program operation and to provide detailed effective assistance should problems arise; plus availability of program upgrades

Cost:

The selection of a number of cost options allows purchase of greater range of software

Vocational Training:

Many of the skills required to use computer programs become a motor habit rather than a cognitive process: once individuals learn to type, they are hard-pressed to state which finger is used to strike a particular key or which series of keystrokes calls up a particular function or menu. Such motor learning may be relatively intact following brain injury. Patients may deny ever having used a computer but demonstrate ability to do so when placed in front of the equipment.

Leisure Activity:

Lack of cognitive stimulation has been demonstrated to result in decreased cognitive abilities over time.  Daily practice on computer programs can provide sufficient stimulation to maintain hard-won cognitive gains, fill leisure time,  provide respite for caregivers, and allow interaction with family members and peers.  Even basic level  games can provide hours of enjoyment for survivors while providing respite for caregivers.