Canadian Association of Occupational Therapists (CAOT) Conference - June 6-9, 2012 - Biofeedback and Mindfulness

1. Amee Le
Applications to Acquired Brain Injury

2. Outline
• CHIRS & ABI clients
• Brief Summary of research on mindfulness
• Brief Summary of research on Biofeedback & Heart
Rate Variability
• Measuring Heart Rate Variability using the emWave
Desktop & Dual Drive Game
• ABI Specific Intervention Technique videos

3. Our clients
• Adults from 18-65
• Moderate to severe brain injuries
• History of substance use
• Mental health disorders and developmental delays
• Both ambulatory and physical impairments

4. Our Clients
Question: What is the best thing about having a brain injury?
Answer: You can hide your own Easter Eggs.

6. Mindfulness
Being mindful is associated with:
• Less emotional stress
• More positive states of mind
• Better quality of life
• Influencing the brain & autonomic
nervous system

7. What is Mindfulness?
• In control of their own thoughts
• There is no need to search for answers outside ourselves
• Change starts from within
• Past and future
• The present is the only place we can make choices
• In the present is where we can affect change
Promoting optimal health in the mind, body, relationships and spirit

8. Key Principles
Being in the Present
Non-judgment
Acceptance, curiosity and openness
Awareness of yourself, transform your thoughts
Break old habits, new ways of responding

10. Biofeedback
• 1980-90s headaches & pain
• Heart rate and skin temperature
• Late 90s biofeedback and ADHD
• Price and technology
• Electroencephalography (EEG) &
Electrocardiography (ECG)
• Computer game & “mind control”

11. Heart Rate Variability (HRV)
• Importance of cardiac rhythms
• Beat-to-beat rhythm shifts
• Inspiration and exhalation
• Aging, illness, and psychological states
• Development of electrocardiograph (ECG)
• Abnormal HRV and sudden cardiac arrest
• Role of HRV in cardiac rehab

12. Evolution of ECG & HRV Technology

13. Heart Rate Variability (HRV)

14. HEARTRATE(BPM)
Seconds
Over Time a Heart Rhythm Pattern Emerges
100
90
80
70
60
50
40
30
20
10
0
8 10 12 14 16 18 20 22 24

15. Incoherence: Impairs Performance–Amplifies Energy Drains
Coherence: Promotes Optimal Performance–Builds Resilience
HEARTRATE
HEARTRATE
Inhibits
Brain Function
(Incoherence)
Facilitates
Brain Function
(Coherence)
TIME (SECONDS)
Heart Rhythms
100 –
90 –
80 –
70 –
60 –
50 –
100 –
90 –
80 –
70 –
60 –
50 –
1 50 100 150 200

19. Typical Treatment Session
Mindfulness & Biofeedback
Quick Reference Card
I. Baseline (5-10 mins)
5 mins - Baseline, Discussion & Updates
2 mins - Breathing Exercise
II. HMI Techniques (5-10 mins)
2 mins - Quick Coherence
2 mins - Heart Lock-in
2 mins - Attitude Breathing
III. Yoga (5-10 mins)
5 mins - Seated Yoga: guided
IV. Mindfulness (10-25 mins)
5 mins - Contemplation with Art & Poetry
10-20 mins - Meditation: guided, visualize, music, nature sounds
Total Session: 30-45 minutes

21. D.D. Injury
• Two traumatic separate injuries
• Dilation of the ventrical (neural atrophy)
• Right occipital infarct (vision)
• Left Cerebellar infarct (motor)
• Atrophy of the left temporal (anteriorly) &
frontal lobe (memory, executive function,
impulsivity)
• Possible brain stem damage – medulla
• Vascular abnormality attached to the left
opthalmic artery (vision)
• Left homonymous hemianopsia (vision)
 D.D. is in his early 50s

22. D.D. Neuropsychological Profile
• Global Intellectual Abilities: full scale IQ Average
• Non-Verbal IQ – Average
• Verbal IQ – Average
• Attention & Processing Abilities Borderline Impaired
• Slow and easily distractible
• Verbal & Language Abilities Average
• Speech is good
• Good vocabulary
• Non-Verbal/Visual Spatial Abilities Relative Strength
• Primary visual spatial skills relatively intact i.e. basic vision to perception
• Complex visual spatial skills borderline low average (integration of both hemispheres)
• Learning & Memory
• Declarative Memory is impaired in both visual and auditory modality
• Procedural Memory relatively intact
• Semantic Knowledge intact
• Attention and working memory is impaired

23. D.D. Neuropsychological Profile
• Executive Function
• Verbal abstract reasoning is average (abstract thinking)
• Non-Verbal reasoning is average
• Impulsive
• Poor planning
• Poor emotional control
• Poor initiation
• Difficulties with organization
• Sensory Motor
• Left homonymous hemianopsia (visual Impairment at the nerve level)
• Fine motor dexterity impaired bilaterally
• Motor speed borderline impaired on the left and profoundly impaired on the right
• Grip Strength impaired bilaterally
• Poor balance
• Mood & Anxiety moderately severe concerns
• Being unable to relax
• Numbness & tingling sensation when I hear sirens
• Difficulties breathing

24. He was referred to OT services managing
his anxiety in relations to falls prevention

26. J.J. Injury
• Two injuries
• One in childhood due to severe trauma to the
temporal and bifrontal lobe that resulted in
surgery & a right temporal lobectomy
• One due to severe trauma that resulted in a
subdural hemotoma (hemorrhage,
compression of brain tissues)
• Surgery (left side frontal temporal craniotomy)
to remove hemotoma (blood pooling)
 Currently in his mid 20s

27. J.J. Neuropsychological Profile
• Global Intellectual Abilities: full scale IQ Borderline Impaired
 Non-Verbal IQ – Average Range
 Verbal IQ – Profoundly Impaired
• Attention & Processing Abilities Impaired
• Verbal & Language Abilities Impaired
 Reading at grade 1 level
 Slurring of speech
 Simple instructions
 Limited vocabulary
 Verbal Abstract Reasoning impaired (ex. banana/strawberries)
• Non-Verbal/Visual Spatial Abilities Relative Strength
 Primary visual spatial skills relatively intact i.e. basic vision to perception
 Complex visual spatial skills relatively intact (integration of both hemispheres)

28. J.J. Neuropsychological Profile
• Learning & Memory
 Declarative Memory is severely impaired in both visual and auditory modality
 Procedural Memory relatively intact
 Semantic Knowledge impaired
 Attention and working memory is severely impaired
• Executive Function
 Verbal abstract reasoning is impaired (abstract thinking)
 Non-Verbal reasoning is average
 Impulsive
 Poor planning
 Poor emotional control
 Poor initiation
• Sensory Motor
 Fine motor dexterity impaired bilaterally, qualitatively better on the right
 Motor speed borderline impaired on the left and severely impaired on the right
 Grip Strength impaired bilaterally
 Pain Diagnosis of Post Traumatic Fybromyalgia

29. J.J. was referred to OT Services
for managing his pain

32. Summary & Clinical Experience
• Client’s frustration levels are quite low during the session
• Most clients really enjoyed the session
• Compliance with attending sessions are high
• Individualized treatment plans
• Software providing feedback
• Facilitates improve awareness & insight
• It’s fun (and concrete)!!

33. Contact information
Amee Le
Community Head Injury Resource Services of Toronto
62 Finch Avenue West, Toronto, Ontario M2N 7G1
416-240-8000 x 284
ameel@chirs.com