Reducing Agitation and Aggression After Atbi a TBI Can Cause Uncharacteristic Agitation

Visions RainbowA Magazine for Acquired Brain and Spinal Cord Injury Professionals, Survivors and Families Rainbow Rehabilitation Centers Inc.

Winter 2011 www.rainbowrehab.com Volume VIII No. 1 Reducing Agitation and Aggression after aTBI A TBI can cause uncharacteristic agitation. Find out what treatment strategies have proven successful

Therapeutic Ultrasound An effective tool for increasing range of motion and reducing pain

Yoga Therapy Exploring the mind / body benefits of an age-old alternative therapy

Whooping Cough Update Cases are on the rise, learn what you can do about it

Promoting Great Oral Care Staying healthy through good oral care practices

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MARCH IS BRAIN INJURY AWARENESS MONTH President’s Corner

LEADERSHIP | TEAMWORK | CULTURE Continuing the Dream

By Bill Buccalo, President Rainbow Rehabilitation Centers

has been just over two and a half would take to do it. At that point, we can every day, as well as the clients I meet IT years now since Rainbow’s true determine if we will or won’t – but not at our homes and centers. We have an founder and inspirational leader passed that we can’t. Creativity. “awesome” group of people that clearly away. Buzz Wilson lead Rainbow in Buzz valued Loyalty, Honesty, and have “that can-do spirit.” I hope they feel many ways over the years, but most nota- Autonomy. He would much rather rein they know Buzz a little through the cul- bly through his focus on the culture and in the super-charged employee than have ture of the organization. a sense of esprit de corps. His legacy is to push forward the unmotivated. During In the time since Buzz passed, there not the accumulation of brick and mor- interviews, he would ask how you spell have been many nice tributes, however, tar, employee head count, or sales vol- “no.” Of course, you didn’t know if he one Rainbow client made a request that ume. Rather, his legacy is best noted by meant “no” or “know.” He was usually a picture of Buzz be displayed at the the sense to which our shared values and looking for “K.N.O.W,” unless of course, Ypsilanti Center by the end of February. mission are carried on, how we relate you were applying for an accounts pay- This is a wonderful idea, Roscoe. We are and respect one another, and how this able position, and then he was probably placing plaques in several of the Centers energy courses through the veins of the looking for “N.O.” The point being is that over the next few weeks in honor of organization. It’s the Culture. Rainbow has always sought out creative, Buzz. They will serve as nice remind- The culture Buzz stood for wasn’t laid intelligent, free-thinking individuals who ers of the man responsible for much of out in a textbook or available in a bul- are highly motivated and not afraid to the culture in which we hope you all let point list. Rather, it was more of an act. “Just get the job done.” enjoy while visiting Rainbow. Buzz was a accumulation of stories, phrases, and He looked out for the little guy—the dreamer— we acted on them and we still repeated actions that made clear what client who couldn’t advocate for him- do. We need to sieze the day. Or as Buzz he valued. Phrases like “do whatever it self, or the employee who didn’t have would say, “Go for it!” takes,” “the customer is always right,” a voice. He would “send a message” and “gotta look out for the little guy.” Or to let folks know that we do care. We “if we don’t do it, who will?,” and “we have done this many ways over the years A Dream Deferred work for them” (“we” being administra- including improvements to our benefit by Langston Hughes tion and “them” being the clients, the plans and obsessing over the safety of What happens to a dream deferred? house staff, and the therapists). clients and staff. It is a risky business. As Does it dry up Through our culture, we believe there a result, there is no such thing as focus- like a raisin in the sun? is no mountain we cannot climb or ob- ing too much on safety. Or fester like a sore — We miss Buzz dearly and in many stacle that we cannot overcome. With And then run? teamwork and persistence, we can serve ways. We work every day to carry on the Does it stink like rotten meat? our clients better, we can get the job legacy that he left behind and to main- Or crust and sugar over— done, we can achieve, and everybody tain the culture. I imagine some days it like a syrupy sweet? wins. “We just need to oar together.” may appear faint, but I assure you, much Maybe it just sags of the time it is coursing. With time pass- Customer Focus. Teamwork. We don’t like a heavy load. look at difficult problems and conclude ing, we now have many new employees Or does it explode? we can’t do it. Rather, we are trained to and clients who never knew Buzz. I am look at problems and determine what it very impressed with the new hires I meet

2 RainbowVisions RainbowVisions 3 www.rainbowrehab.com WINTER 2011 Features 10 Reducing Agitation and Aggression after Traumatic Brain Injury On the Joe Welch, LLP, CBIS, CAAC Cover Choosing the Right Summer Program Cognitive challenges 17 that occur after a brain injury can contribute 20 Promoting Great Oral Care to frustration and Angie Spears, MA CCC-SLP, CBIS agitation. Read about treatments that work. in each issue Page 10 2 President’s Corner – Continuing the Dream Bill Buccalo, President, Rainbow Rehabilitation Centers

4 Medical News – Whooping Cough Kim Wagenknecht, BSN, RN, CRRN

6 Therapy Corner – Yoga Therapy Sara Fink 14 Technology Corner – Therapeutic Ultrasound Tina Kowalski, DPT, CBIS

24 Industry Conference & Event Calendar news at Rainbow 4 6 20 26 Neuro-Behavioral Program in Oakland Cty. 28 Our Newest CRRNs 28 Rainbow's Employees of the Season 29 New Professionals at Rainbow 800.968.6644 www.rainbowrehab.com

Editor — Barry Marshall Copyright February 2011 – Rainbow Rehabilitation Centers, Design — Celine DeMeyer Inc. All rights reserved. Published in the United States of America. No part of this publication may be reproduced in any manner whatsoever without written permission from E-mail questions or comments to: Rainbow Rehabilitation Centers, Inc. Contact the editor: [email protected] [email protected].

If you do not wish to receive RainbowVisions, www.RainbowVisionsMagazine.com please e-mail: [email protected]

2 RainbowVisions RainbowVisions 3 Medical news

an epidemic in Michigan and across the U.S. Whooping Cough

The best way to prevent pertussis is to get vaccinated. Make sure infants and young children get their recommended shots on time.

By Kim Wagenknecht, BSN, RN, CRRN ities across the U.S. have been hit hard with a rise in pertussis, or what is Rainbow Rehabilitation Centers commonly known as “whooping cough.” Pertussis, caused by the bacteri- C um Bordetella pertussis, is an upper respiratory tract infection that is easily spread through airborne droplets when an infected person coughs or sneezes. During the first few months of 2010, several states reported increased cases of pertussis compared to the same time period in 2009. California had the most reported cases last year, logging 6,700 cases and reporting that 10 infants have died from it. In Michigan, the increase was first observed in the second half of 2008 and continued throughout 2009 and 2010. There were 902 reported cases in 2009, and as of Oct. 31, 2010, there were already 1,092 cases. In contrast, there were 315 cases reported in 2008, with an average of 340 cases reported annually since 2003. Symptoms The disease starts like a common cold with symptoms of runny nose, congestion, sneezing, mild cough and fever. After one to two weeks, severe coughing begins. Infants and children with the disease cough violently and rapidly, over and over, until the air is gone from their lungs and they are forced to inhale with a loud “whooping” sound. The coughing can last for weeks, even months. Adults and adolescents typically will have a milder form of pertussis; however they can still easily

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spread the infection to others. Pertussis is most severe for ba- WHOOPING bies. More than half of infants less than one year old required COUGH CASES IN As of hospitalization. MICHIGAN October 31, 2010 Why is there such a big increase in pertussis cases? 1,092 There are several reasons for the marked increase in pertussis here in Michigan and across the country. They are: 902 • Decreasing immunity in teens and adults. Many have not yet gotten their Tdap vaccine booster, and more than half of the cases reported in 2010 have been in teenagers and adults. • Unvaccinated children. Parents who opt out of vaccinat- 315 ing their children create pockets of vulnerability in the community. 2008 2009 2010 • Change in pertussis testing. A newer test, called a PCR, has become the dominant method of testing, and most likely, more cases are being detected by the new test than Adolescents and adults may need to be revaccinated, even if in the past. they were completely vaccinated as children. This is especially Treatment important for families with new infants. If someone thinks they have been exposed, they should im- Additionally, on a daily basis, one should carefully cover the mediately call their doctor. Usually, an antibiotic is prescribed. nose and mouth when coughing or sneezing, wash hands often Until a person has been on antibiotics for five days, they with soap and water and drink plenty of fluids to avoid dehy-  should try to stay away from other people and especially in- dration. fants and young children. How can pertussis be prevented? References: The best way to prevent pertussis is to get vaccinated. Make http://publichealth.ewashtenaw.org sure infants and young children get their recommended shots http://www.cdc.gov/pertussis on time. Consult a doctor for a vaccination schedule. http://www.annarbor.com Protection from the childhood vaccine fades over time. http://www.michigan.gov

Clinical Complications Pertussis can cause serious and potentially life-threatening urinary incontinence. More severe complications can include complications in infants and young children who are not fully pneumothorax, rectal prolapse, and subdural hematomas. vaccinated. Adolescents and adults can also develop complications from In infants younger than 12 months of age who get pertussis, pertussis, but they are usually less severe in this older age group, more than half must be hospitalized. Hospitalization is most com- especially in those who have been vaccinated. mon in infants younger than 6 months of age. Of those infants In one study, hospitalization rates were 0.8% for adolescents and who are hospitalized with pertussis, approximately 50% will have 3% for adults with confirmed pertussis. Pneumonia was diag- apnea, 20% get pneumonia, 1% will have seizures, 1% will die nosed in 2% of each group. and 0.3% will have encephalopathy (as a result of hypoxia from The most common complications in another study of adults with coughing or possibly from toxin). pertussis were weight loss (33%), urinary incontinence (28%), syn- Of those infants younger than 12 months of age who die: cope (6%), and rib fractures from severe coughing (4%). Refractory pulmonary hypertension is a common, severe com- Other complications can include anorexia, dehydration, epistaxis, plication that contributes to death hernias, and otitis media. More severe complications can include Encephalopathy occurs in approximately 20% of cases encephalopathy as a result of hypoxia from coughing or possibly Other complications can include anorexia, dehydration, diffi- from toxin, pneumothorax, rectal prolapse, subdural culty sleeping, epistaxis, hernias, otitis media, and hematomas, and seizures.

4 RainbowVisions RainbowVisions 5 Therapy corner

By Sarah Fink Founder and CEO of YogaMedics

6 RainbowVisions Clients of Rainbow’s Pediatric Program participate in yoga groups. RainbowVisions 7 www.rainbowrehab.comwww.rainbowrehab.com WINTERWINTER 20112011

Why use yoga to treat Traumatic Brain Injury? Yoga helps improve flexibility and muscle strength, and promotes relaxation. But there’s more…

very year, an estimated 1.7 million Americans sustain But there’s more. traumatic brain injury (TBI), according to the Centers • Yoga decreases anxiety and depression. for Disease Control and Prevention. Most people • Yoga regulates dopamine levels. Research shows that low E who have experienced aTBI are treated in emergency dopamine levels contribute to addiction and anxiety disor- rooms and released. ders as well as Parkinson’s Disease. But that doesn’t mean they return to life as usual. The lasting effects of TBI may only be repaired step-by-step • Yoga increases the release of endorphins, natural mood en- through strategic application of traditional therapies, and new hancers housed in the brain. therapies such as the up-and-coming, clinically-based yoga Simply put, yoga helps people relax, eliminate stress and therapy. Combining the age-old wisdom of yoga with the latest increase feelings of well-being. medical evidence, Rainbow Rehabilitation Centers has paired For TBI patients, the values and practices of yoga help pro- up with YogaMedics to run custom classes and individual ses- foundly in healing. Yoga’s breathing techniques increases brain sions for clients to help them handle life after brain injury. (see activity, focus and awareness. sidebar pg. 8) For those with frontal lobe or forehead injuries who often ex- Many factors impact health. Social support, stress manage- perience loss of simple movement and the ability to multi-task, ment, coping ability and the immune system all play a part in a medically-based yoga builds the physical body and reteaches person’s health. Mind-body medicine addresses all of these. skills needed to successfully sequence. Mainstream medicine traditionally looks at injury and illness Parietal lobe injuries near the back and top of the head can as separate from the person, mind-body medicine considers eliminate one’s sense of body awareness, causing challenges in the cumulative impact of many factors in a person’s wellness self-care. Yoga increases awareness and removes distractions. picture. Other types of brain injuries also benefit from yoga. Whether The National Institutes of Health defines mind-body therapy it’s balance, coordination, movement or simply seeking calm- as “interventions that use a variety of techniques to facilitate ness, yoga is one way to strength and wellness. (ezinearticles.com) the mind’s capacity to affect bodily function and symptoms.” Because mind and body are linked, teaching control of Some people are more familiar with the term “alternative med- the mind helps the body get better. Traditional medicine ad- icine,” which refers to any healing practice that falls outside dresses symptoms of injury or illness. Mind-body medicine the scope of conventional medicine. addresses the whole person for total wellness. (National Center for Societies around the world have long associated good health Complementary and Alternative Medicine) with more than just taking medicine. Daily diet, exercise, so- While these methods are gaining in popularity and public cial habits and other factors contribute to a person’s wellness. attention, they are not new. Until 300 years ago, every medical Why use yoga to treat TBI? Yoga helps improve flexibility and system treated mind and body as one. During the 17th century, muscle strength, and promotes relaxation. Westerners separated mind and body — the body as a machine with replaceable parts and the mind as a self-sufficient Continued on page 8

6 RainbowVisions RainbowVisions 7 Therapy yoga therapy Continued from page 7 corner emotional entity. (en.wikipedia.org/wiki/Mind) While such a perspective led to advances in surgery, trauma care, pharmaceuticals and more, it also diminished the amount of inquiry doctors put into a patient’s emotional and spiritual life, impeding total ability to heal. Stanford University Integrative Psychiatrist James Lake, MD, said: “Extensive research has confirmed the medical and mental benefits of meditation, mindfulness training, yoga, and other mind-body practices.” v

Yoga Therapy at Rainbow Every Tuesday and Thursday, YogaMedics therapist Elizabeth Schafer comes to Rainbow’s Apartment Program to serve clients there. She follows a specialized pro- tocol over 12 weeks, combining messaging, education and physical poses to help students with healing. She works with Rainbow’s interdisciplinary therapy teams to ensure that yoga is integrated into a client’s plan of care. She is also responsible TRIANGLE POSE for documenting the experience that each client receives during therapy. “Each week builds upon the week prior,” said Schafer, who studied public health and worked with the U.S. Government but knew nothing about treating TBI until she came to YogaMedics. “When you start talking about car accidents and veterans from Afghanistan and Iraq, you’re finding problems that may never go away,” she said. “We combine science and medicine and the practice of yoga that we know to be so beneficial physically and mentally, and take it to a clientele that experiences a range of limi- CHILD'S POSE tations and struggles. YogaMedics is a beautiful combination of yoga and public health.” The messaging in YogaMedics brain injury classes relates yoga to TBI recovery. “At the beginning, we talk about motivation to live differently. We work on building trust and safety and security within the group,” said Schafer. “We talk about building awareness of physical sensations and ultimately accepting thoughts that clutter the mind.” Physical poses used in yoga enhance confidence and self-control. “Child’s Pose” relieves anxiety. “Back Bends” open the heart and chest while easing anxiety and depression. Through the sessions at Rainbow, “people have gotten stronger, and have real- ized improved range of motion, balance and flexibility,” said Schafer. “Our clients BACK BEND POSE use deep breathing techniques to handle anxiety.” Guided imagery helps them envision the life they want, maintain motivation and believe it into existence. Rainbow also has a Yoga Group at its Pediatric program in Oakland County. Run by a Rainbow therapist, children and young adults alike actively participate in the group and realize the benefits of yoga.

References: National Center for Complementary and Alternative Medicine , http://nccam.nih.gov Wikipedia, http://en.wikipedia.org/wiki/Mind http://soulflowyogi.com/Soul_Flow_Yoga_Ask_Flo.html http://ezinearticles.com/?Yoga-for-Brain-Injury&id=966226

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Become a Certified Brain Injury Specialist Join more than 1,500 Certified Michigan Professionals

The Academy of Certified Brain Injury Specialists (ACBIS) As a service to our brain injury community, Rainbow offers offers a national certification program for entry-level free training courses to prepare for the CBIS exam. Nurses, staff and experienced professionals working in the field case managers and other professionals who partner with of brain injury. ACBIS provides those interested with an Rainbow and have at least one year of experience working opportunity to learn about brain injury, to demonstrate in the field of traumatic brain injury rehabilitation are their learning with a written examination, and to earn a invited to attend. nationally recognized credential.

DATES: Training sessions will be held every Thursday from 8:00 a.m. – 9:30 a.m. July 14 – September 15, 2011 LOCATION: Rainbow Rehabilitation Centers Corporate Headquarters 38777 Six Mile Rd., Suite 101, Livonia, Michigan 48152 INSTRUCTORS: Lynn Brouwers, MS, CRC, CBIST and Heidi Reyst, Ph.D., CBIST

To participate in CBIS training, please contact: Lynn Brouwers at [email protected]

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Reducing Agitation and Aggression after Traumatic Brain Injury

By Joe Welch, LLP, CBIS, CAAC Rainbow Rehabilitation Centers

patient of mine, “Mike,” sustained a traumatic brain disciplines including biological, sociological, and cognitive injury and had immediate, frequent verbal outbursts processing theory. Aand was occasionally physically aggressive. He would Biologically, some studies indicate that high testosterone and yell and make very disturbing postures and threats. low serotonin levels are associated with increased levels of ag- After several sessions of very simple, repetitive breath con- gressive behavior in people. People who are experiencing pain trol practices, Mike began to take deep breaths independently or high environmental temperatures have also been found to be whenever he felt his anger arise, and would proudly proclaim more easily agitated. There is strong evidence that higher ambi- “I am breathing…I am breathing!” ent temperatures increases human violence (Psychological Bulletin, This young man was successfully able to achieve much great- 1989). er self-control over his impulsive (and sometimes explosive) Behaviorally, a person may act out aggressively to get atten- anger and he eventually discharged from treatment. tion, to increase access to things they want such as soda or Mike’s story is not unusual among those with a brain injury. candy, to escape or increase stimulation such as loud noises, or People will often experience periods of agitation immediately to avoid an unwanted task such as making one’s bed1. following an injury due to the disruption of neurological func- Cognitive challenges that occur after severe brain injury may tioning and accompanying confusion. Some people who are contribute to frustration and agitation. Memory and attention recovering from brain injuries may continue to experience pe- deficits make learning very difficult. Speech and comprehen- riods of agitation for months after their initial accident. A small sion impairments can be equally frustrating. Imagine suddenly percentage of people continue to experience states of agitation becoming unable to effectively communicate your needs or long after acute hospitalization, seriously disrupting their qual- understand what others are saying. Add other problems like ity of life and creating many challenges for the people who care pain and physical limitations that make doing what was once for them. routine, now impossible. In essence, independently getting Causes of agitation and aggression one’s needs met after a brain injury can be fraught with frustrat- Agitation may best be defined as high irritability and displays ing hurdles. of frustration that can include aggressive verbal and physical Understanding basic features of agitation and aggression behaviors such as yelling, swearing, property destruction, strik- Verbal aggression is the most common form of frustration that ing others, and self-injury. In most cases, family members or is exhibited. Raising one’s voice or swearing may be persistently caregivers are the most frequent targets. Fortunately, clinically or intermittently problematic. Threatening to act out physically derived treatments can help reduce or eliminate many of these can be impulsive, defensive, or in response to pain. Verbal ag- problems that are specifically related to the brain injury. gression may be goal-directed to avoid unwanted task demands Physical aggression has been studied by various scientific or events that are perceived as aversive. People may learn that

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Effective Strategies for Reducing Aggression

51. Allow a verbally aggressive person time to vent. 2. Use language such as “I will talk to you about this when you are calm.” 3. Use breathing control strategies to reduce agitation. 4. Implement reward strategies that reinforce self control such as non-contingent rewards. 5. Use collaborative problem solving. Provide empathy, help the person to define the problem, invite them to help solve the situation collaboratively.

threatening to get upset or act out may also get them things emphasized, as well as, weaknesses that can be minimized by they want. This is best described as instrumental aggression. focused treatment in this area. All in all, better communication Over time, a person may use threats of “getting mad” to get means less frustration. others to do things that they can’t themselves or just don’t want Verbal techniques are recommended for verbal aggression1. to do. Posturing occurs by threatening to enter someone else’s Not immediately responding to hostile verbal behavior pro- personal space or by clenching or raising one’s fist. Verbal ag- vides a brief time out, and is an effective verbal intervention. gression and posturing may be the best indicators of impend- Allowing someone to vent during a period of frustration and ing physical aggression. reducing the audience can lessen verbal outbursts such as yell- Physical aggression is defined as causing harm toward an- ing or swearing. By allowing for time to process this informa- other person or oneself. Property destruction falls into this tion, people can move toward more socially accepted methods category (like punching a wall) and is a form of “re-directed” of gaining attention, asking for help, or accepting “bad news.” physical aggression. In treatment settings, events of physical A consistently used phrase such as “I will talk to you about this aggression towards another person are uncommon and usually when you are calm” may provide the cue needed for someone short in duration and low in intensity, but can be “crisis-like” to stop yelling or using profanity. for people not familiar with post-acute rehabilitation. Self- Physical therapists help a person to regain functional effec- injurious behavior is uncommon but is often an expression of tiveness and thus reduce frustration by relearning how to move frustration and can be as serious as cutting oneself or banging independently, safely, and successfully. As fatigue can be an ones head against objects. antecedent to irritability, strengthening muscles in therapies Self-injurious and aggressive behaviors, and the settings they and exercising regularly helps build endurance. In addition, occur in, must be thoroughly understood to develop treatment recognizing that a patient may plans to help reduce them. need to take breaks during Treatment works certain tasks can help by Understanding a person’s cognitive strengths and weaknesses providing everyone and incorporating them into individualized treatments plans is Continued on page 12 the focus of all disciplines of rehabilitation. Speech & language pathologists help people redevelop both receptive and expressive communication abilities. Exercising specific cognitive domains with a supportive speech therapist can greatly improve relationships and reduce frustration. Everyone has communication strengths that can be

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Continued from page 11 with reasonable expectations of performance and to plan Empathy is where a person’s feelings are heard by another accordingly. person in a supportive relationship and is a core tenet of hu- In a comprehensive level of care program, occupational and manistic psychology3. Used unconditionally, empathy rein- vocational therapies also add an extremely important dimen- forces active communication. Identifying the specific problem sion by helping people develop the skills necessary to safely behavior with the patient in explicit, understandable terms complete activities of daily living and thus vastly improving helps generate greater awareness. Invitation is the process that independence. engages the patient to brainstorm with the therapist ways to Recreational therapists help people to relearn the all-too- solve the problem, thus actively rehearsing executive function- familiar management of downtime, with fun, social, and con- ing and problem-solving skills. structive planning and assistance to provide the highest quality Other proven treatment strategies of life and to reduce the potential frustration of believing that Reward programs can reduce both verbal and physical aggres- there is “nothing to do.” sion. Implementing reward strategies that reinforce self-control, Behavioral therapy is a treatment used with people who are and don’t reward acting out, is an important key to progress in easily agitated after their injuries. Having a psychologist con- rehabilitation. duct a functional analysis of Non-contingent rewards (NCR) specific problem behaviors can provide access to enjoyable ac- help determine why someone Everyone has communication tivities and attention are supplied continues to act out verbally strengths that can be emphasized as or scheduled throughout the or physically long after their day. Basic needs, attention, and initial injury. Intermittent dis- well as weaknesses which preferred activities are provided plays of frustration, whether can be minimized by focused for unconditionally2. There are verbal or physical, can almost indications that this type of re- always be reduced or elimi- treatment. All in all, better ward system probably achieves, nated in frequency, duration, communication means over time, the greatest reduction or intensity by providing a safe in problem behavior and greatest environment with people who less frustration. quality of life. are prepared to deal with these Differential Reward for Other problems in an atmosphere of (more appropriate) behavior unconditional positive regard. (DRO) requires more planning and adjustment during treat- Anger management ment, but is proven to be effective at reducing problem behav- At Rainbow Rehabilitation Centers, mental health therapists iors such as self-injury and physical aggression4. The rewards help patients redevelop their emotional regulation abilities. used to shape behavior can be: giving attention, tangibles (such Most people respond very well to a combination of breath con- as spending money), or a time out from a task demand. trol practice and cognitive therapy to reduce the duration or Rainbow Rehabilitation Centers incorporates this methodol- intensity of periods of agitation2. Teaching these behavioral and ogy into its Adult Levels Program. thinking skills in therapy sessions and modeling them outside “The Adult Levels Program incorporates a client’s goals with of formal sessions will help increase generalization. clinical time frames that everyone can see, understand, and Collaborative Problem Solving (CPS) is another well-con- refer to,” said Dr. Colin King, director of Behavioral Services structed strategy when working with people who have explo- at Rainbow and developer of the Adult Levels Program. “The sive tendencies7. This method helps integrate a person’s level of Adult Levels Program was developed using proven behavior executive functioning and emotional regulation into a system modification strategies such as differential rewards.” of interaction that pursues reasonable expectations, reduces A specific example of how this works is when someone, who outbursts, and teaches skills. receives an allowance that is only intermittently contingent upon behavior, continues to act out in an unsafe or agitated The essence of CPS involves a three-step plan: manner. Making their allowance consistently contingent upon 1. Providing empathy (plus reassurance) toward the person not acting out for specific periods of time (such as daily or week- 2. Defining the problem situation ly) has helped many people overcome serious behavior issues. 3. An invitation to collaboratively solve the issue.

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Rewards that are consistently contingent upon periods of Referrals to addictionists (physicians specializing in substance stability have been shown to reduce problem behaviors5. Thus, abuse disorders and pain management) are made when indi- DRO is a form of contingency management and is effective in cated and incorporated into the comprehensive treatment plan. reducing problems such as self-injurious behavior and physical Medication 2 aggression . Family education and the involvement of the en- The use of medications in many cases can have demonstrated tire treatment team may be required for this to be successful. benefits in reducing agitation and aggression. In cases where Transitioning from non-contingent schedules to more dif- there is depression associated with problem behavior, certain ferential or contingency-based schedules will help someone anti-depressant medications have also shown efficacy in pro- achieve greater levels of stability. This is done by making re- viding relief from persistent agitation or aggression. wards (such as attention or tangibles) more contingent upon Selective serotonin re-uptake inhibitors (SSRIs) have shown longer periods of stability, and has been shown to reduce prob- to reduce agitation in some cases where there is high irritabil- 5 lem behaviors . ity associated with depression. Anti-epileptic medication and Integration of substance abuse recovery into brain injury certain anti-hypertensive medications have also been shown to rehabilitation has greatly helped many people be successful. help some patients suffering from anger management problems At Rainbow, Certified Advanced Addictions Counselors can achieve greater stability. be actively involved in treatment planning, as well as provide For more serious or generalized aggression, sedative or anti- individual counseling. Facilitated groups are held at Rainbow psychotic medications may greatly improve a person’s ability to and transportation is provided to community-based support cope. All medication programs that include psychotropics require groups (such as Alcoholics Anonymous) when a person is ready. regularly scheduled assessment by physicians experienced in brain Continued on page 30

About the author

Joseph Welch, LLP, CBIS, CAAC Psychologist, Rainbow Rehabilitation Centers

Joe is a psychologist specializing in brain injury and addictive disorders and is a certified crisis prevention instructor. He holds a master's degree in Clinical/Behavioral Psychology.

Joe has been a Mental Health Therapist at Rainbow Rehabilitation Centers since 2005.

References: 1. International Association of Nonviolent Crisis Intervention. 2. A comparison of procedures for programming non-contingent reinforcement schedules. Kahng, S.W.; Iwata, B., DeLeon, I.; Wallace, M. (2000); Journal of Applied Behavior Analysis. 3. On Becoming a Person. Rogers, Carl. (1961) 4. The functions of self injurious behavior: An experimental-epidemiological analysis. Iwata, B. et al. (1994); Journal of Applied Behavioral Analysis. 5. The role of attention in the treatment of attention maintained self-injurious behavior: Non-contingent reinforcement and differential reinforcement of other behavior. Iwata, B., Pace, G., Cowdrey, G., & Miltenberger, R., (1994 ); Journal of Applied Behavior Analysis.

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Tina Kowalski, PT, DPT, CBIS Rainbow Rehabilitation Centers Therapeutic Application of Ultrasound

ltrasound was identified during increased cellular activity. is not the goal of treatment (although UWorld War II when the use of Acoustic microstreaming is the result there is always some residual heat effect SONAR was observed to heat and dam- of pressure forming in the fluid sur- during any ultrasound therapies). Goals age underwater life. This finding led rounding a cell, which facilitates com- of non-thermal, or pulsed, ultrasound to the use of ultrasound in the clinic ponents required for tissue healing. involve essential components of tissue to heat biological tissues, including During thermal ultrasound, sound healing including edema reduction, pain muscle, tendons, ligaments, and fascia. waves cause tissue vibration that creates modulation, and increased capillary These tissues all have high collagen heat in the treatment field. Secondary density which in turn increases local content, creating a lower threshold for effects from the production of heat in- circulation. heating the material. clude increasing blood flow to tissue, Clinical Applications Ultrasound creates sound waves that which delivers important nutrients and Among other clinical applications, ultra- compress the material to which it is removes waste. sound is most commonly used in cases applied. It is defined as a sound greater Effects of Ultrasound of soft tissue shortening and pain control than 20,000 cycles per second (Hz). Ultrasound may have different effects on in the traumatic brain injury (TBI) popu- Therapeutic ultrasound has a frequency tissues depending on the parameters set lation. The therapist uses a coupling me- of between 0.7 MHz and 3.3 MHz. during treatment. dium, typically gel or water, when ap- These frequencies are able to reach tis- Thermal effects of ultrasound include plying ultrasound to the treatment area. sue depths of two to five centimeters. any type of heating characteristic, and is Many individuals with brain injuries The sound waves travel through the used for the reduction or control of pain, often present with tightening of muscles transducer head (the part of ultrasound muscle spasms (by heating the myo- due to inactivity, poor positioning, that contacts the tissue), which in turn neural junction), increased circulation muscle imbalance, and abnormal tone. converts the electrical energy to sound and soft tissue extensibility, and altering Abnormal tone decreases an individual’s energy. nerve conduction velocity (how fast a ability to move muscles through the In non-thermal ultrasound, this en- signal travels from the brain or spinal full range of motion and often leads to ergy produces waves which exert pres- cord to a given muscle). contractures. In this situation, ultrasound sure on the cell walls, caused by cavi- Thermal effects usually last for 5-10 can apply deep heat to the muscles with tation and microstreaming. Cavitation minutes following treatment, so any limited range, as well as stimulate the can be described as the effects of the subsequent treatment is applied shortly golgi tendon organs to activate the pro- sound waves on the fluid within the after, such as stretching or soft tissue tective relaxation reflex. cell. Bubbles form and begin to ex- mobilization (massage). The use of ultrasound has been shown pand and contract, causing increased Non-thermal effects include those to be effective in treating shortened diffusion across the membrane and characteristics where heating the area muscles, both in research and in clinical

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Therapeutic Application of Ultrasound

settings. However, as stated, the treat- Precautions are based on the individ- and should use ultrasound in addition to ment window following ultrasound is ual being treated, and clinical judgment evidence-based therapy and other mo- short and must be taken advantage of to should be utilized in these situations. dalities as necessary. v achieve results. Ultrasound should be Precautions for ultrasound include im- used in conjunction with range of mo- paired sensation, cognition, and com- References: tion exercises, orthotics, and/or active munication due to risk of burning with Physical Agents in Rehabilitation: exercises as able. the use of thermal ultrasound. Other From Research to Practice Pain is also a common issue among precautions include acute inflammation, Michelle H. Cameron, pp. 195-215 individuals with TBI. It can stem from a use in close proximity of epiphyseal Enhancing treatment outcomes with variety of sources, and while it is wise to (“growth”) plates, fractures, and breast therapeutic modalities: Electrotherapy treat the source of pain, ultrasound can implants. and Ultrasound. David Draper, aid in controlling pain during treatment Contraindications, or situations where Ed.D., ATC. Course workbook. sessions to achieve functional outcomes, ultrasound should NOT be used, include independence, and comfort. The non- direct application over implanted stimu- thermal effects of ultrasound have the lators, cancerous lesions, anterior neck greatest effect on pain modulation. triangle, eyes and reproductive organs, local infections (sepsis, osteomyelitis), Precautions and Contraindications About the author As with any treatment, there are precau- metal in the treatment field, pregnancy, tions and contraindications of which the growth plates, central nervous sys- Tina Kowalski is a graduate of the therapist must be mindful. tem tissue, joint cement, and plastic components. University of New England in Portland, Conclusion ME with a Doctorate in Physical Therapists have a metaphorical “tool Therapy. She has clinical experience box” when treating individuals with TBI. in a variety of settings, including Ultrasound is just one tool in the box, pediatric and adult rehabilitation. Tina and can be used in various situations to increase functional outcomes for indi- is a Physical Therapist at Rainbow’s viduals with physical impairments and NeuroRehab Campus®. functional limitations. The clinician should be well versed in the rationale and treatment methods of ultrasound before utilizing it in the field

14 RainbowVisions RainbowVisions 15 After School

& Saturday Day Therapies and skill building for Programs children and teens with brain injuries Specifically designed for academic and social success, our programs integrate structure, group and/or individual therapies, personalized tutoring, recreational activities and social skills training.

To register or for more information call... 800.968.6644 E-mail: [email protected] www.rainbowrehab.com

16 RainbowVisions RainbowVisions 17 www.rainbowrehab.com WINTER 2011 Choosing the right Summer Program for children and young adults with special needs

or many adults, summer camp conjures a host of memories such as F scary ghost stories, swimming lessons, and gooey s’mores. Children today, including those with special needs, have an array of summer options in addition to that classic camp experience. Kids with special needs want to participate in activities, make friends and be accepted just like everyone else. Parents want a program that allows their children to maintain the progress they’ve made during the school year. Everyone will want an environment that is safe, supportive and fun. Continued on page 18

16 RainbowVisions RainbowVisions 17 Choosing the right Summer Program for children and young adults with special needs

Continued from page 17

Before making a decision, you’ll want to consider the variety of summer programs available. Does the program make accommodations for special needs? Accessible wheelchair ramps, special diets and trained medical staff are sometimes available at mainstream camps. Your child will have the opportunity to meet and socialize with peers and participate according to his or her abilities. If, however, your child needs structured therapy throughout the summer then you’ll want to consider a different type of program. Special needs summer camp There are two types of summer programs for kids with special needs. The first is designed to look and feel just like a classic camp. These camps aim to remove barriers to activities that non-disabled children take for granted. There are special needs summer camps for children with physical or mental impairments, behavioral issues, and medical conditions such as diabetes and cancer. Aside from the benefits that everyone receives from a camp experience, children at a special needs camp meet and make friends with others who share their particular abilities. Therapeutic summer programming Another type of summer programming is therapeutic and comprehensive. These structured programs employ professionally trained pediatric therapists and have an appropriate staff-to-child ratio. Individual therapies are available as well as opportunities for ABOVE: Spending time with friends and enjoying therapeutic learning. Medical personnel are available. Parents who are concerned that a summer day are important for the children who their child continues to make gains in therapy and academic skills would choose this participate in Rainbow’s Summer Fun! Program. type of program. ABOVE RIGHT: “Noodling around” in the pool is more Therapeutic programming doesn’t mean all work and no play. Art, music, sports and than just fun, it’s aquatic therapy. Participants may organized games are incorporated into the therapies. Cooking projects reinforce math increase joint mobility, range of motion, muscle skills and health lessons, yoga and equestrian activities help to improve balance and strength and endurance while in the water. core strength, art activities are designed to improve eye-hand coordination. Older children can also benefit from health management, career-building activities and volunteer opportunities. Other factors to consider STAFF When choosing a program make an effort to meet the staff and tour the facilities. Is it easy to access the director? What is the staff experience level and education? Are medical professionals available? What is the staff-to-child ratio? Are they proactive in learning about your child’s needs? What are their safety plans and procedures? PHILOSOPHY Find out if the program has particular goals or objectives for their participants. Are children separated by age, gender or interest? Sometimes mixing ages and grade levels creates disparities in sports and academic abilities. That can lead to frustration for participants of all ages, and the program should foster a sense of community during each child’s stay. COMMUNICATION Letters home were a mainstay of the classic camp experience, but

18 RainbowVisions RainbowVisions 19 www.rainbowrehab.com WINTER 2011

SAVE the DATE! June 20 – August 26, 2011

Therapeutic programming for children, teens and young adults with brain injuries.

ABOVE: Academic performance needn’t be a casualty of summer. Rainbow’s Summer Fun! Program includes academic support through one-on-one and group lessons.

special needs programs should have a communication plan that goes well beyond this. If you are considering an overnight program, what is the their policy for han- g into... dling communications home? How do they handle common issues such as home- ilin Sa sickness, illness and behavior problems? LICENSING Ensure that the program you are evaluating is properly licensed. Know that licensing requirements vary from state to state. Does the program per- ! Su un form background checks on prospective staff members? Do they insure that indi- mmer F viduals transporting children have valid driver’s licenses? Do care providers have up-to-date CPR or first-aid certifications?

There are many factors to consider, but the most important may be your child’s Two Locations in Southeast comfort. Many children feel intimidated by unfamiliar people and surroundings so Michigan: you may want to reassure them about the new experiences ahead. Keep in mind Oakland County that the best summer programs allow opportunities to acquire new skills, build con- and fidence and foster independence. Above all, remember that any program for kids Genesee County should be safe, fun and provide great memories for years to come. v A therapeutic References: summer program www.camppage.com/summer-camp-choosing.htm where we don’t count kidshealth.org/parent/system/ill/finding_camp_special_needs.html the days…we make the www.kidscamps.com days count! www.rainbowrehab.com To register or to learn more about Summer Fun! Programs, call toll-free

800.968.6644

18 RainbowVisions RainbowVisions 19 Especially for People Who Have Sustained a Traumatic Brain Injury

Promoting Great

Too tired to brush your teeth? By Angie Spears, MA CCC-SLP, CBIS Too busy to floss? If you’re tempted to skip these daily tasks, remember that Rainbow Rehabilitation Centers your smile and oral hygiene depends on these simple dental care habits. Maintaining good oral hygiene is one of the most important things you can do for your teeth and gums. Healthy teeth not only enable you to look and feel good, they make it possible to eat and speak properly, as well as de- crease your risk of diseases. Someone who has experienced a traumatic brain injury (TBI) faces many challenges. The simplest daily tasks can be difficult, including basic day- to-day routines. Oral care can be overlooked when a person experiences a TBI secondary to possible physical and cognitive changes. However, these

20 RainbowVisions RainbowVisions 21 www.rainbowrehab.com WINTER 2011

impairments should not shadow the importance of oral care. why extra attention There are many adaptive and assistive equipment devices that for persons with disabilities? can be used for proper oral care, despite the TBI. Oral health There are two significant predictors of pneumonia that are di- education has received increased attention and awareness over rectly affected by oral hygiene. First, dependency for oral care the last few years as poor oral hygiene can be an indicator for is directly correlated with poor oral health. (Vigild- 88) Those who additional health issues. depend on others to brush and floss their teeth are much more oral care and your health likely to be at risk for aspiration pneumonia. (Langmore et al, 1998) It is not surprising that your mouth is full of bacteria. The oral The second significant predictor of pneumonia is the number cavity is a moist and dark place, often filled with food, chew- of decayed and/or missing teeth. Decayed and missing teeth ing gum, fingernails, pen caps, etc. Some bacteria are good, create a direct source of bacteria. (Jette et al, 1993) Bacteria thrive and they can fight off germs and viruses. However, some bac- in the open space and worsen tooth decay, thus increasing the teria are not healthy for your body, as they cause infection and likelihood of causing pneumonia. disease if not properly cleared from the mouth. Statistics show Physical impairments, uncooperative hands, and unreliable these bacteria make the human bite more harmful than a dog memory from brain injury are just a few reasons someone may bite. require help completing oral care. Oral care can be extremely Bacteria attaches to the surface of teeth, gums, tongue, and difficult to perform on ill and non-cooperating patients. cheeks. They live in plaque, which is a colorless biofilm that stay hydrated naturally builds up on teeth. If plaque is not removed, it starts Both the tongue and saliva play a role in maintaining good oral to harden within 48 hours. Within 10 days, the remaining health. The tongue is always moving around in the oral cavity plaque becomes dental tarter, which is rock hard. Tarter can- (in most situations) which helps break up bacteria colonies. The not be removed with a toothbrush, so it must be removed by a tongue has a rough surface and brushes against teeth while eat- dentist or dental hygienist. If plaque is allowed to build up, the ing and talking. bacteria it holds can cause tooth decay, gingivitis, pneumonia Saliva keeps the oral cavity lubricated. It is frequently swal- and other illnesses. Multiple studies have linked oral pharyn- lowed, thereby diluting and removing bacteria from the oral geal colonization with respiratory infections and illnesses. cavity throughout the day. For example, saliva clears sugars (American Journal of Infection Control 2005;33:527-41) and dietary acids, which aids in protecting the teeth against Those who depend on others to brush and erosion. When saliva is decreased, possibly because of an infection or a side effect from a prescribed medication, a per- floss their teeth are much more likely to be at son may experience dry mouth, also known as xerostomia. risk for aspiration pneumonia. Xerostomia leads to increased bacteria in the mouth because food debris accumulates along with dental plaque without nor- mal salivary flushing. Oral health is now seen as a marker for more serious health Dry mouth can also lead to: oral discomfort, loss of teeth, problems. Poor oral hygiene can no longer be considered just a taste and appetite disturbances, oral infections, dysphagia (dif- local problem, but one for the health of the whole body. Many ficulty swallowing), and speech difficulties. These can lead to a studies have recently connected gum disease with some serious decreased immune system, as they further stress gastrointestinal health problems including cardiovascular disease, strokes, and function, loss of appetite, fear of eating, weight loss, and/or diabetes. Gum disease can cause bacteria to enter the blood- malnutrition. stream where they attach to fatty deposits in heart blood vessels. Dehydration occurs when the amount of water leaving the This can cause blood clots and may lead to heart attacks. Severe body is greater than the amount being taken in. Some common periodontal disease has an adverse effect on sugar levels, in- causes of dehydration include: diarrhea, vomiting, sweat, dia- creasing the risk of diabetic complications. betes, and burns. Pneumonia is a common respiratory illness in which there Dehydration is often overlooked and untreated due to in- is inflammation of one or both lungs. Pneumonia is caused by adequate recognition of some of its causes and symptoms. bacteria, viruses, and fungi. One way of acquiring pneumonia (Copeman, 2000; Vogelzang, 1999) Symptoms include: dry mouth, low is by aspirating the bacteria and viruses living in your mouth. or no urine output (concentrated urine appears dark yellow), A recent study found that in 66% of the cases of pneumonia, not producing tears, sunken eyes, muscle cramps, lighthead- the organism causing the pneumonia came from the mouth. edness (especially when standing), and lethargy or comatose (Garrcuate et al., Scannapiceco et al.) (with severe dehydration). Continued on page 22

20 RainbowVisions RainbowVisions 21 Promoting great

Continued from page 21 Dehydration is a major risk factor for oral and dental disease secondary to reduced liquid intake, reduced salivary flow, and build-up of plaque. practicing preventive care Daily preventive care helps stop problems before they develop. Some diseases and conditions can make dental disease and tooth loss more likely, but most of us have a good deal of control over the health of our teeth and mouth. Promoting good oral care may reduce the likelihood of pathogenic bacteria being present in the oral cavity. The most important thing you can do is to brush and floss your teeth daily. Brushing provides the friction required to remove plaque from the large surfaces of the teeth and from just under the gums. Flossing removes dental plaque from between your teeth. Using foam swabs (often referred to as toothettes) Suction toothbrushes attach to a suction removes debris and secretions from the oral cavity, but does not remove plaque from machine and reduce the risk of aspiration between teeth or sheltered areas. pneumonia by removing unwanted fluids Some people who have sustained a traumatic brain injury and/or experienced from the oral cavity. another life altering event may benefit from adaptive equipment to make good oral hygiene easier. Suction toothbrushes are often used for patients who do not have a safe/functional swallow following a brain injury and receive most, if not all, of their hydration and nutrition from a percutaneous endoscopic gastrostomy (PEG) tube. Some people who have Suction toothbrushes attach to a suction machine and reduce the risk of aspiration pneumonia by removing unwanted fluids from the oral cavity. A yankuer can also be sustained a traumatic brain attached to a suction machine. A yankuer is a hollow tube made of metal or dispos- injury…may benefit from able plastic with a curve at the end. It can be utilized during oral care to remove ex- adaptive equipment to make cess secretions, debris and saliva to help prevent diseases and pneumonia. Continued, adequate oral care is a necessity for healthy living. The research con- good oral hygiene easier. necting poor oral hygiene to serious health problems is alarming especially for those who are dependent on others for oral care. Keeping the mouth and oral cavity clean reduces bacteria and the chance of infection. v

10 Tips for Improving Oral Hygiene

1. Encourage routine visits to dentist 2. Brush teeth daily 3. Never use mouthwash with alcohol (alcohol dries the mouth) 4. Encourage cessation of smoking 5. Reduce intake of sugary snacks 6. Encourage adequate hydration and nutrition 7. Use soft bristled toothbrushes 8. Use sodium bicarbonate toothpaste with fluoride 9. Floss whenever possible 10. Use water soluble moisturizer to lips and oral mucosa (soothes and hydrates the lips and oral tissue)

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References: Almsthal & Wilkstrom, 1999 Lagerlof & Oliveby 1994 American Journal of Infection Control 2005;33:527-41 Langmore et al. Dysphagia 1998; 13: 69-81 Copeman, 2000; Vogelzang, 1999 Millns B, et al, Acute Stroke Predisposes to Oral Dawes 1983 Gram-Negative Bacilli-A cause of Aspiration Garrcuate et al., Scannapiceco et al. Pneumonia? Gerontology 2003; 49: 173-76. Gross et al, 1992; Copeman, 2000; Kleiner, 1999 Sarosiek, 2000 Jarvinen et al 1991 Vigild- 1988

About the author

Angie Spears, MA, CCC-SLP, CBIS Speech-Language Pathologist Angie has a master of arts degree in speech-language pathology from Cleveland State University and a bachelor of arts degree in communication disorders from Central Michigan University. Angie has worked with the traumatic brain injury population at Rainbow Rehabilitation Centers for four years, and has two years of experience treating the geriatric population with a range of neurological impairments. She has lectured on both recall and swallowing at local and state level. Angie is a Certified Brain Injury Specialist and a member of the American Speech-Language Hearing Association.

Request a ride online! We get youReady www.rehabtransportation.com get you Set so you can GO! The most challenging part of the journey can be getting out the door — washing, dressing, preparing for the day. Rehab Transportation drivers know this and are trained in caring for individuals with special needs including brain and spinal cord injuries. We get you safely from point A to point B, and if you like, we give you expert personal care assistance at either point too.

Personalized, attentive services 24/7, 365 days a year. Ready, Set, GO!

Call 800.306.6406

22 RainbowVisions RainbowVisions 23 Conference & Event Schedule 2011Winter/Spring March May March 8, 2011 May 2-4, 2011 Case Management Society of America MALA 2011 Conference & Trade Show Detroit Chapter Dinner Conference The Lansing Center, Lansing, MI Farmington Hills Manor, Farmington Hills, MI For info, please visit: www.miassistedliving.org/conference For info, please visit: www.cmsadetroit.org May 6, 2011 March 10, 2011 WMBIN Annual Symposium DMC/RIM 60th Anniversary Celebration Crowne Plaza, Grand Rapids, MI Fox Theater, Detroit, MI For info, please visit: www.maryfreebed.com For info, please visit: www.dmc.org May 10, 2011 March 11, 2011 Case Management Society of America Educational Rehabilitation Symposium Detroit Chapter Dinner Conference Radisson-Kingsley Inn, Bloomfield Hills, MI Farmington Hills Manor, Farmington Hills, MI For info, please visit: www.acclaimedhc.com/events.html For info, please visit: www.cmsadetroit.org March 12, 2011 May 13, 2011 Carnival of Care U of M / St. Joseph Mercy Rehab Nursing Conference Sterling Inn, Sterling Heights, MI Kensington Court, Ann Arbor, MI For info, please visit: www.carnivalofcare.com For info, please email: [email protected] March 15, 2011 May 15 – 18, 2011 Case Management Society of America Contemporary Forums Psychiatric Nursing Conference Greater Grand Rapids Kalamazoo Chapter Hyatt Regency, San Francisco, CA Lansing, MI For info, please email: www.contemporaryforums.com For info, please email: [email protected] May 17, 2011 March 23 – 26, 2011 Case Management Society of America Contemporary Forums Psychiatric Nursing Conference Greater Grand Rapids Kalamazoo Chapter Sheraton Society Hill, Philadelphia, PA Muskegon, MI For info, please visit: www.contemporaryforums.com For info, please email: [email protected] March 29, 2011 Michigan Association of Rehabilitation Nurses Annual Education Conference June Laurel Manor Conference Center, Livonia, MI For info, please visit: www.miarn.org June 1–3, 2011 Michigan Self-Insurer’s Assoc. Spring Conference Grand Traverse Resort, Traverse City, MI April For info, please email: www.michselfinsurers.org June 14-17, 2011 April 7 – 10, 2011 Case Management Society of America NICM/ACMA Case Management Conference 21st Annual Conference and Expo Orlando World Center Marriott Resort, Orlando, FL Gonzalez Convention Center, San Antonio, TX For info, please visit: www.acmaweb.org For info, please visit: www.cmsa.org April 9, 2011 BIA of Michigan, 13th Annual Spring Tribute Legacy Society Dinner; An Evening with John Grogan July Suburban Collection Showplace, Novi, MI For info, please visit: www.biami.org July 12, 2011 April 21, 2011 BIAMI Eastern Grand Invitational Golf Outing Michigan Health and Rehab Conference The Inn at St. John's, Plymouth, MI Best Western Sterling Inn, Sterling Heights, MI For info, please visit: www.biami.org For info, please visit: www.firsttoserve.com July 21, 2011 April 29, 2011 BIAMI West Grand Ivitational Golf Outing Detroit Medical Center/Rehab Institute of MI Boulder Creek Golf Club, Belmont, MI For info, please visit: www.biami.org Rehab Symposium Motor City Casino and Hotel, Detroit, MI For info, please visit: www.dmc.org

24 RainbowVisions www.rainbowrehab.comwww.rainbowrehab.com WINTERWINTER 20112011

MBIPC Michigan Brain Injury Provider Council RINC Rehabilitation & Insurance Nursing Council meetings MEMBERS ONLY

Registration at 11:30 a.m. / Lunch at Noon Presentation begins at 12:45 p.m.

March 18, 2011 Topic: Advanced Stress Management Learn Over Lunch Speaker: Mary Jo Gavin, Ph.D. Location: Functional Recovery Program at Sinai-Grace Hospital Meeting times are noon – 2:00 p.m. 25900 Greenfield, Suite 502 (Registration at 11:30 a.m.) Oak Park, MI 48237 Cost: MBIPC Member $25 / Non-member $60 For info or RSVP contact Mary Mitchell RSVP to: Brenda Blind at 248-968-5393 by March 7, 2011 734-482-1200 or [email protected] April 15, 2011 March 8, 2011 Topic and speaker: TBD Topic: Updates on MDCH Programs and TBI Prevention May 20, 2011 Speaker: Michael Daeschlein and Linda Searpetta Topic and speaker: TBD MI Dept. of Community Health (MDCH) June 17, 2011 Location: Kellogg Center, East Lansing, MI Topic and speaker: TBD

April 12, 2011 RINC meetings are presented the third Friday of each month. Topic: TBI and Sexuality: A Multi-Dimensional Perspective. For more information on meetings and membership contact Speaker: Barbara Barton, MSW, Ph.D. Adrienne Shepperd: 248-953-4079 Location: Holiday Inn West, Livonia, MI

May 10, 2011 Topic: Mild Traumatic Brain Injury MARCH IS BRAIN INJURY Speaker: Karen Bergman, RN, Ph.D., CCRN AWARENESS MONTH Location: Applause Banquets & Catering in Grand Rapids, MI

June 14, 2011 March 16, 2011 Topic: Violence in the Workplace. Brain Injury Awareness Day on Capitol Hill Washington, DC Speaker: Judy Arnetz, Ph.D., MPH, PT Location: Holiday Inn West, Livonia, MI The day’s events include: Brain Injury Awareness Fair For updates on meetings, visit www.rainbowrehab.com 10 am – 1:30 pm NOTICE: The conferences and events information listed on these pages is dated information. For the most up-to-date Brain injury rehabilitation briefing information on industry-related conferences and events, please 1:30 pm – 3:30 pm visit: www.rainbowrehab.com Select Education & Publications from the top menu The Brain Injury Association of America and the Congressional Brain Injury and then select Conferences & Events Task Force, along with other stakeholders are coordinating the day’s activities. Updated biweekly, the site offers the dates, locations and Visit www.biausa.org for more information. topics of the industry's most prominent events.

RainbowVisions 25 News @ Rainbow Expands its Neuro- Behavioral Program for Adults Rainbow’s successful adult neuro-behavioral program is expanding into Oakland County with the opening of a new residential home. This program will offer adults with neuro-behavioral challenges an effective treatment option in a community setting. The structured program features staff specially trained in behavior modification techniques—principles involving positive reinforcement, peer mentoring and modeling. Educational pursuits and/or vocational training are encouraged in the neuro-behavioral program, and substance abuse counseling is pro- About the home… vided when necessary. Designed especially for adults with neuro- Led by psychologist Colin King, Ph.D., the goal of this program is behavioral needs to transition individuals to the most independent and appropriate Six private bedrooms environment possible while giving them the tools to manage their Three fully accessible bathrooms behaviors. Open floorplan featuring barrier-free living areas, TV room, bedrooms and kitchen

Private therapy room on site

Alarm system to promote personal safety

Full laundry facilities

To learn more about availability or to schedule a tour, call Rainbow’s Admissions Department at: 800.968.6644

Rainbow therapist You may never know the positive impact you have on someone until years later. Just ask Carole MacQueen, OTR/L, NDTC at Rainbow. A few years ago, Carole was a develops lecture series mentor to then-intern Rosanne DiZazzo-Miller, an occupational therapy student at Eastern Michigan University working on her master’s degree in OT. Since that time, Rosanne has gone on to become an Assistant Professor at Wayne State University in Detroit and has earned a doctoral degree in occupational therapy. In October of last year, Dr. DiZazzo-Miller asked Carole if she would deliver a lecture series to her OT students on Neuro-Developmental Treatment (NDT), an advanced therapeutic approach practiced by OTs. Carole was honored by the invitation and jumped at the chance. She developed a lecture series that included a one-hour lecture on theory and two, two-hour labs, where the students were on mats working on handling techniques. The student’s loved Carole’s interesting lecture and interactive labs. Carole recalls Dr. DiZazzo-Miller as being one of “the best students I ever had!”

Carole MacQueen, OTR/L, NDTC Congratulations, Carole, on a fantastic lecture series!

26 RainbowVisions RainbowVisions 27 www.rainbowrehab.com WINTER 2011

New program at Rainbow creates opportunities for employees Late last year, the Executive Committee at Rainbow Rehabilitation Centers an- nounced a new director-in-training program to support our growth and ensure con- sistent, quality care to our clients no matter where they receive treatment. Because of this program, there exists an unprecedented opportunity for our employees to advance to roles of increasing responsibility. This new program calls for additional directors to help us expand our services beyond existing boundaries. As the company grows, there will be more opportunities for our employees who have the necessary skills to develop into these leadership roles. To kick off this program, four people have been selected to participate in the initial year-long training program that will culminate with two of them being promoted to a Divisional Director, while potentially leaving two others available to fulfill future opportunities. They are: Anne Ulrich, Bob Wancha, Dr. Mary Newton, and Joe Welch. Join us in congratulating them and encourage them as they take this step in their careers at Rainbow!

Vocational Experience after a Traumatic Brain Injury

Regain confidence

Develop skills

Reinforce positive habits

Work toward employment goals

Earn a paycheck

Vocational training and rehabilitation are vital after a traumatic brain injury because cognitive skills—which impact problem solving, concentration and abstract thinking—are often altered. Rainbow Industries provides a safe, supportive environment where people work toward employment goals while earning a paycheck. Located in Ypsilanti, Michigan 734-480-4277

26 RainbowVisions RainbowVisions 27 News @ Congratulations Dr. Mary Newton Rainbow is pleased to recognize Case Manager and Mental Health Specialist, Mary Newton on earning her doctorate in Industrial Organizational Psychology (I/O) from Capella University in Minnesota. I/O uses evidence-based testing to assess workplace functionality and improve productivity. It is also helpful in assisting individuals to adapt to the greater community and world of work, an important component of Dr. Newton’s responsibilities at Rainbow. We congratulate her on this significant accomplishment!

Congratulations to Rainbow’s newest CRRNs! Rainbow Rehabilitation Centers is proud to recognize three new Certified Rehabilitation Registered Nurses on its staff. Jill Coval Kathleen Sobczak Kim Phelps Congratulations to our colleagues on this significant accomplishment!

Rainbow Employees of the Season Fall 2010 Rehabilitation Assistants Ann Arbor Apartments: Quanda Merced Home Health: Sandra Smith After School/Summer Program: Erin Chatman Maple: Riad Alhakim Arbor: Marybeth Elder NRC North: Keisha Oliver Bell Creek: Katherine Coon-Johnson NRC South: Terrell Mitchell Belleville: Vanessa View Page: Tina Milligan Birchwood: Alyssa Cooper Paint Creek: Angeleec Andron Carpenter: Melissa Potters Parkview: Carrie Farmer Elwell: Kendra Blackwell Rehab Transportation: Gary Devine Farmington: An’Twoin Dowell Shady Lane 1: Chenoa Mays Garden City Apartments: Cecil Newlin Southbrook: Krystle Richardson Gill: Diane Marshall Spring Valley: Kelly Goodman Glenmuer: Nicole Lefebvre Textile: Cheryl Hinkle Golfside: Denise Genereaux Oakland Townhouse: Cynthia Lindberg Hillside: Kathy Boraggina Whittaker: Sarah Porter Highmeadow: Nicholas Mascaro Woodside 1& 2: Samantha Bass & Kristi Vaupel

Residential Administrative Staff Professional / Therapy Staff Program Managers Keith Schenkel Lillian Durecki, Randy Green, Michelle Smith Pamela Braden Anne Ulrich, Marty Humphrey, Maintenance Staff Cheryl Helber Amanda Miuccio Jeff Schmitt and Bob Adams Please join us in congratulating these outstanding staff members! For Spring and Summer 2010 Employees of the Season, go to www.rainbowrehab.com

28 RainbowVisions RainbowVisions 29 www.rainbowrehab.com WINTER 2011

New Professionals at Rainbow

Melissa Miller, BSN Angeline Kimrey, BBA Clinical Nurse Manager Corporate Recruiter Melissa joins the team at Rainbow’s Angeline joins Rainbow's administrative NeuroRehab Campus®. She has worked team at the Livonia Corporate Center. She is for St. Joseph Mercy Health and Oakwood a graduate of Baker College with a bachelor's Annapolis. Melissa holds a Bachelor of degree in Business Administration. Angeline Science in Nursing from Eastern Michigan comes to Rainbow with three years of University. recruitment experience.

Jocelyn Kubert, PT, DPT Erin Erickson, OTR Physical Therapist Occupational Therapist — Functional Recovery Jocelyn joins the staff at the NeuroRehab Erin holds a Bachelor of Science degree from Campus® as a physical therapist. She has Southern Illinois University and recently clinical experience working with the TBI received a master’s degree from Baker College population and earned a Doctor of Physical in Flint, MI. Erin joins the team at Rainbow's Therapy degree from Central Michigan Functional Recovery division in the Flint area. University.

Elina Gorelkin, PT, DPT Katherine Bink, OTR Physical Therapist Occupational Therapist Elina comes to Rainbow with clinical Katherine holds a Bachelor of Business from experience in inpatient and outpatient settings Michigan State University and a master's in and joins our team in Ypsilanti. Elina earned Occupational Therapy from Rush University. a bachelor's degree from the University of She joins the staff at Rainbow's NeuroRehab Michigan and a Doctor of Physical Therapy Campus® in Farmington Hills, MI. from the University of Colorado-Denver.

Lillian Durecki, RN Isabelle Pattarozzi, PT, DPT Nurse Case Manager Physical Therapist Lillian holds a Bachelor of Science in Nursing Isabelle joins the staff at Rainbow's Oakland from Madonna University and joins Rainbow’s Center in Farmington, MI. Isabelle received staff at the NeuroRehab Campus®. She has her undergraduate education at Loras College over nine years of experience working as a in Dubuque, IA and earned a Doctorate of Registered Nurse in home care. Lillian has Physical Therapy from Rosalind Franklin also worked as a Clinical Instructor at Eastern University in Chicago, IL. Michigan University.

Felina Swasey Sue Arney Co-receptionist Human Resource Assistant Felina joined Rainbow as a Rehabilitation Sue joins out team with 5 years of experience Assistant (RA) in July 2010 and the Clerical in the field of private investigations, assisting team as co-Receptionist in January 2011. in background investigation and information. She is currently attending Wayne County Her organization specialized in Workers Community College where she is working Compensation. Sue is wonderfully organized toward her degree in Nursing. Felina addition to our team. continues to serve as a RA at the residential homes several shifts per month.

28 RainbowVisions RainbowVisions 29 One Thousand Words

Insisting on using our own clients in most of our photo shoots can prove to be challenging, but the outcomes are worth it. Take the case of this photo. We wanted to capture some of the activities at Rainbow’s Summer Fun! program in Genesee County. This young client was playing shy even after all of our efforts to get her to smile. Our tenacity finally paid off as she gave us a smile that only a six year old could. Rainbow’s Summer Fun! Program is gearing up for a new season which begins June 20, 2011. Call 800.968.6644 for information.

Reducing Agitation Continued from page 13 injury rehabilitation to ensure that the saf- employees are required to maintain their behaviors, enjoy life, and reach est, best tolerated medications are used for certification with the International their potential. When plans of care are improvement in self-control. Association of Non-violent Crisis person-centered and adjusted for individ- Safety First Intervention (IANCI), attending classes ual needs, most people who are initially Crisis prevention and intervention train- every year with mandatory competency challenged with profound frustrations ing is also used by health care profes- tests. When interventions are conducted can learn over time to defeat these ob- sionals to provide for the safety and by professionals using proven and safe stacles and progress safely, productively, v security of their patients1. At Rainbow, strategies, people learn how to control and happily.

30 RainbowVisions RainbowVisions 31 www.rainbowrehab.com WINTER 2011

Home- and community-based rehabilitation services for adults, teens and children

Physical, Occupational and Speech Therapy Home and community therapeutic intervention for individuals with brain and spinal cord injuries

Functional Home Assessments Assistance in determining durable medical equipment and attendant care needs

Home Modification Assessments Recommendations for home modifications in order to create a barrier free or wheelchair accessible home/living environment

Work Site Assessments On-site modification recommendations

For more information call:

E-mail: [email protected] www.functionalrecovery.com

Functional Recovery 800.968.6644 is a division of www.rainbowrehab.com 30 RainbowVisions RainbowVisions 31 Presorted Standard U.S. Postage PAID 38777 Six Mile Road, Suite 101 Permit 991 Livonia, Michigan 48152 Ypsilanti, MI

INSIDE: Reducing Agitation and Aggression after Traumatic Brain Injury Page 10

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Rainbow Facility Locations

GENESEE COUNTY Functional Recovery / Home and Community-Based Rehabilitation 8245 Holly Rd, Suite 102A Grand Blanc, MI 48439 MAP 810.603.0040 DETAIL AREA OAKLAND COUNTY Oakland Treatment Center 32715 Grand River Ave. Farmington, MI 48336 248.427.1310 RIPROC Vocational Center 32619 Grand River Ave. Farmington, MI 48336 248.471.9580 NeuroRehab Campus® 25911 Middlebelt Road Farmington Hills, MI 48336 248.471.9580 WASHTENAW COUNTY Ypsilanti Treatment Center 5570 Whittaker Rd., Ypsilanti, MI 48197 734.482.1200 RIPCO Vocational Center 834 Railroad St. Ypsilanti, MI 48197 734.480.4277

WAYNE COUNTY Rainbow Corporate Headquarters 38777 Six Mile Rd. Livonia, MI 48152 734.482.1200 Home Care Program Headquarters THROUGHOUT MICHIGAN Residential Locations 38777 Six Mile Rd. Livonia, MI 48152 Home Care & Home and Community-Based Rehabilitation 734.482.1200 734.482.1200 For information call toll free: 800.968.6644 E-mail: [email protected] Visit: www.rainbowrehab.com