Producer: Alright, and welcome back to Full PreFrontal where we are exposing the mysteries of executive functions. I am here again with our host, Sucheta Kamath.

Good morning, Sucheta, always good to be with you. Very much looking forward to your second conversation with Dr. Jerry Hoepner, but before we get to it, we're going to talk about John Cox, cognitive rehabilitation, and Harrison Ford. What the heck?

Sucheta Kamath: And Tabasco sauce, Todd.

Producer: And Tabasco sauce, yes. So I think I know where this might be going.

Sucheta: Well, it's great to be with you, Todd. I am going to share a wonderful story with you about John Cox. So John Cox was a cocky, self-assured successful 36-year-old lawyer who one day decided to take his motorcycle for a spin, and on July 2nd, 1979, he was hit by a car. He went flying in the air, landed 28 feet away, only to endure a severe traumatic brain injury. The next thing, what we found is that he was in coma for four weeks and when he regained consciousness, he discovered that he had lost his ability to talk. He was paralyzed on his left side and obviously, he was in no condition to go back and practice law.

Now, what was so interesting about John Cox is, before his injury, he was quite well-known in Indiana. He had a successful law practice, he has served in the Indiana legislature, he was a corporate counsel for Evansville, and he also had made frequent appearances on local television and had come to be known as quite the celebrity. He was interestingly full aware of his gifts and he took them seriously, but his wife, Joan, was once heard saying that John was always kind of on an ego trip. The reason I tell you this story is the brain injury took a toll on not just John and his abilities but on their marriage. So recovering from the traumatic brain injury was not easy. He had to work around the clock with all kinds of therapists and it needed a full commitment from his wife and of the collective effort of his community for John to return to his law practice after two years. The interesting thing was that even though he did come back, he really was not in the best of shapes to practice law. The law firm itself kind of pushed him aside, he had a lot of challenges in serving in full capacity or in the position that he was, and that itself took a long time to rehabilitate.

So the reason I'm sharing this story is not really about John Cox but what happens next, so fast-forward, almost 15 years go by and one day, Mr. and Mrs. Cox, Joan and John, rented a movie from Blockbuster called Regarding Henry which the facts, as you and I have talked about this earlier, and fictional story of a man called Henry Turner who was shot with a gun and who endured a severe traumatic brain injury, and Harrison Ford played the role of Henry Turner. Now, I, myself have a few pet peeves with this movie because they show a physical therapist doing the job of a speech and language pathologist, so I was not happy about that at all, and what was another interesting thing about that, that they showed that Harrison Ford's character was this pain in the butt, arrogant, obnoxious guy who suddenly has a change of heart and becomes this divine transformed human being, and that's not the case in my practice that I've seen, but what was interesting about connecting back to John was Mrs. Cox kept a diary each night, capturing their ordeal, not just hers but the whole family's ordeal, and eventually produced a 325-page manuscript which she titled kept Breaking the Tape, and three years later, when they got their bearing back, Joan Cox submitted the manuscript to every possible publisher and only to find out that it was rejected, so nothing happened to that manuscript, so 10 and 12 years later, here she is in her home watching this Blockbuster movie to discover that this is actually her husband's story, and so she, of course, the couple sued Paramount pictures, the movie producers, and the screenplay – screenwriter Jeffrey Abrams on the grounds of copyright infringement. In that, they cited 112, I think, similarities Regarding Henry and their own life.

The reason I'm sharing that, because our guest today is going to shared some light on the journey of recovery, but as I mentioned, you know, in 1950s, AA, first hit television in the movies. Alcoholism as a disease or struggles with excessive drinking and addiction was captured as a problem and there's a solution such as AA was shown on big screens in 50s for the first time, and it wasn't until 90s that we began to even talk about rehabilitation, which is my field, and I was kind of thrilled to see something showing the real-life story of people who are going through such arduous process of regaining skills and repatching relationships with the family, and dealing with the shaken sense of self, and then at best, they did a bad job showing Henry Ford getting therapy from a physical therapist. So I really have been optimistic about this process that as we go through and as our culture becomes more aware, maybe the work that we do in the field of speech and language pathology and the meaningful change that we help bring can be showcased.

So with great joy, I get to introduce our guest Dr. Jerry Hoepner who is a fellow speech and language pathologist, and my guest has done the first interview last week so I encourage people to listen to that, but he's an associate professor of neurogenics at the University of Wisconsin and he is a co-developer of the UW system SOTL ThinkTank, an annual disciplinary consortium of faculty interested in evidence-based instruction and scholarship of teaching and learning research. He is a founding editor and editor at large of the Teaching and Learning in Communication Sciences and Disorders Journal. Dr. Hoepner's research has been published in a variety of journals and just to name a few, is Traumatic Brain Injury or the Journal of International Interactional Research and Communication Sciences and Disorders. His particular interest includes self-assessment, video self modeling, and coaching everyday partners of individuals with traumatic brain injury. Just like Mrs. Joan Cox or Henry's wife in the movie, he also researches teaching pedagogies and self-assessment in university students, and Dr. Hoepner's clinical interest include utilizing everyday routines to reduce demands on working memory and optimizing executive functions.

So my total delight to have him on the show, and this time during our interview, we will be talking a lot more about the actual rehabilitation process.

Producer: Well, it promises to be a fascinating conversation. Yeah, you mentioned Tabasco at the very, very top of the show and that's always bothered me about the movie Regarding Henry, is that all it took to get a guy who couldn't speak was the book Tabasco on his food, and then all of a sudden, he's talking normally, so it is Hollywood, you kind of get how they do what they do. They have to take dramatic license but you kind if–

Sucheta: Yeah, and with that, actually, I guess people in India who eat a lot of spices should not have any aphasia or any speaking difficulties after a stroke or after a traumatic injury.

Producer: Mm-hmm, mm-mm. Well, what are you going to say? It's Hollywood. Alright, well, like I said, this is going to be a great conversation with Dr. Jerry Hoepner, so let's get to it. Here is Sue's second conversation with Dr. Jerry Hoepner.

Sucheta: Welcome to the podcast, Jerry, I'm so delighted to have you a second time. As I get started, we have kind of discussed at length in our previous episode what executive function is and how does it impact development as well as how it looks like, what it looks like when it's impaired. In this segment, I want to really focus on how do we diagnose executive dysfunction as well as how do we manage it, and this will be of great interest to many of our listeners. So let me get right into it.

 So tell me, why should we diagnose executive dysfunction properly?

Dr. Jerry Hoepner: Great question. I think one of the keys to answering that is really thinking about where to measure executive functions. I'm really convinced that they take place in real-world settings and the challenge with that is that a lot of the standardized assessments that we use to measure executive functioning pull people out of that real-world context, and I'm not saying that you should throw away the standardized assessments, but they don't always give us the best picture of how that person is going to perform at home, at work, in school, in the community, those kinds of things. So I think it's important to take that information to get from really well-designed standardized assessments and couple that with information that we get from something that is individually designed to match the wants and needs of that person that you are working with, and that means finding out what they want and need to do and creating assessments that are individualized that address how they perform in those real-world contexts, so that gives them more meaningful information about what performance is going to be like in the real world. Does that make sense?

Sucheta: Yes, so you mean if we take certain neuropsychological tests that we give to our clients or patients, the instructions are very clear and specific, and people make sure that the student or the patient understands it, and a lot of times, what our experience is, that compensates for their difficulty one has with executive function which is if they understand it, they can do it but if they have to figure it out on their own, they don't understand it. So that's why you mean we need to have real-life applicability or the dynamism versus that static or very specific evaluation process?

Dr. Hoepner: Yeah, that's a good way of thinking about it. When we pull them out of that environment, we eliminate those environment demands, like what is going on from an auditory standpoint, from a visual distractor standpoint, and we pull them into a context that is actually supportive to them because it doesn't have all of those external demands, and it may even control what's happening in terms of that person's internal thought line which can also be distracting. So if we know that they're going back to the school setting, we would want to do an assessment that puts some of those same demands that they would encounter in a school setting. If they were going back to a work setting, we would want to create an individualized interaction or assessment that required them to do the same kinds of things that they would do at work and experience at least similar kinds of distractions and demands that they would experience in that situation.

Sucheta: Got it, and that probably then really impacts your decision regarding how to design the treatment for it based on kind of what factors the person is having most difficulty with is what you will then eventually incorporate in your training or treatment of it, correct?

Dr. Hoepner: Absolutely, and that kind of an assessment really lends itself very directly to treatment because you're constantly manipulating, kind of changing the level of demands that that person is encountering. We often use the terms "dialing up" and "dialing down," right? We want that person to be somewhat successful. I don't want them to completely fail. That kind of assessment information doesn't tell me much if you failed but I want to know what level they are successful and what level of support or demands that they can handle, and then as we move into intervention, we can adjust those demands, right, so that if they are struggling, we reduce their demands and over time, we're kind of inching up those demands, whether it's noise or visual distractions, or interruptions, or side conversations, all of those things that might happen in a real-world conversation or interaction, I should say, we're going to, from an intervention standpoint, kind of dial those up as that person is able to tolerate more of that and to start to regulate their own behavior a little bit better.

Sucheta: Yeah, and I find this approach really works because you are helping the patient exactly at a place where the need is. You're not creating a teaching or developing these arbitrary or abstract skills which has no bearing on their real life, so you're connecting the dots for the patient or the client who struggling with these issues.

So let me get into this, my favorite part of this conversation, which is cognitive rehabilitation. So what evidence do we have that cognitive rehabilitation does work?

Dr. Hoepner: So there's a fair amount and a growing amount of evanescence out there and there's some really good resources that put it in – maybe not late-term – but pretty approachable terms in terms of kind of the general takeaways for how to structure cognitive rehabilitation. So someone who is interested in this, there is a site called the ANCDS site. It stands for the Academy of Neurogenic Communication Disorders and Sciences. They have a bunch of open source resources about what kinds of interventions work best and how you might approach them. There's also an international expert group and the acronym is simply INCOG, and again, they have some really good information about what the evidence says about which techniques work best.

Sucheta: And we will link that on our website so people can have access to it. So tell us a little bit about how to begin the treatment, what kind of principles that you put in place and what kind of framework you use when you treat patients with a brain injury or executive dysfunction?

Dr. Hoepner: Sure. So what I'm thinking about executive function, and I would kind of lump in working memory, that ability to hold information in your mind's eye and then do something with it, so that's necessary when we read a book so we know who the characters are as we read along if necessary, when we have a conversation, so we know how to respond to what the other person said, and to hold what we are thinking until it's our turn. Whenever we do mental calculations or try to make a decision that is an internal mental decision, we have to use that kind of thinking.

So to be able to intervene for that, there's these pretty basic approaches that we use and I'll put those in this context that we talked about before of dialing up and dialing down demands, so the first thing that we do is we just consider the demands within their environment and especially early on in their rehabilitation, it's important for us as the clinicians and as the family members to be able to modulate or control that environment for them, so we're doing things like turning off the TV or perhaps closing the door to their room, even drawing the shades so that they have fewer external demands and are more likely to be able to complete whatever the task is effectively. Now, eventually, we will want to provide less scaffolding in that way and/or help them to be able to make those environmental changes for themselves, but early on, it often is on us to make those changes.

The second thing that we do is we work on things that conserve that working memory or processing capacity. There's a few ways that we approach that. One is through those routines and habits that we talked about before. We know that habits and routines don't take much executive functions at all. As the name implies, they occur rather automatically once they're established and because of that, it can conserve or retain that precious processing fuel for making in-the-moment decisions for making appropriate social responses, those kinds of things. So those can work really well, and another part of that conservation process is using other cognitive functions or constructs that are less affected by let's say a brain injury or tend to be there or present earlier in development, and we'd called those implicit learning. So just briefly, there are two types of learning in memory. There are those explicit types of learning in memory where we learn things on purpose, so you can all recall going through a stack of notecards and memorizing definitions, kind of remembering them on purpose. That's explicit, but there are also situations where you learn by just being in that context and you might not even know how or when you learned it, retains it into that context, and so does any type of repetitive learning, especially motor learning kinds of tasks or procedural kinds of things where you are following the steps, and because of that, again, it puts fewer demands on executive functions and learning on purpose.

The last part is just to be able to kind of strengthen their attention control or regulation and their capacity for merging memory over time that's working directly on the problem to strengthen that ability to have control over that function.

Sucheta: That's so thorough and comprehensive. I think I really like the way you have broken it down for our listeners. The one piece that I will complement, add to what you're saying is, when I think about like, transitioning the patients from simple or more explicit to more implicit and more next level of complexity, I introduce novelty, ambiguity, and abstractness, and the more unclear the instructions, the greater the demands on that novel adaptive responses and I find that kind of comes closest to real-life situations where we don't get any manual or instructions, right?

So that brings me to these components of executive processes, if you can go, maybe give us a quick framework or strategies, or how you train them, that will be really helpful, and because there are many parts that you can talk about, let's see if you can address maybe working memory, organization and planning, memory skills, and attention. How do you train them?

Dr. Hoepner: Good question. So starting with that working memory, we defined that as that mental workspace and also, that short-term memory goes along with that. It's one of those things that we can train directly but it's difficult to make change, right? So we all have some innate capacity and whether it's developing or whether that capacity has been disrupted or compromised by a brain injury, something like that, it takes quite a bit of effort to be able to improve that working memory. That's just a general learning principle. That means we have to do what we would call "high doses" of practice and that's really the same for attention training as well. We know that working memory and attention training tends to be pretty domain-specific learning and all that fancy term really means is that it doesn't generalize to other related kinds of tasks. The way that we can strengthen that development is to help that person to become more aware of that process, so on the front end of the task, having to make some predictions on how they might doing the task, so you are about to do task B, right? How long do you think that will take you? How accurate do you think you will be or how many do you think you will complete in a certain amount of time? By making those predictions, a person will have something to assess their judgments and processing on after-the-fact, and we move directly into them just doing the task, and on the tail end of that, reviewing how they did, why they did well if they did, or why they didn't do well, and that starts to help them develop some knowledge of the environment that they are in and strategic behavior. That's really valuable because then they can use those skills that's out in the real world. 

So for example, as they say, "Well, I think I did really well today because I have a good night's sleep last night," then we can make that association, "Oh, so having good and being well_rested helps you to be more focused, helps you to accomplish more," yup? Or they might say, "We had our meeting at a different time today and I haven't eaten lunch yet, I think that's what I didn't do quite as well." So whatever those associations are helps them to recognize, here's what I need to change to assure that I'm at my best. So that's a good way of addressing that issue. Actually, in terms of organization and planning, this process of thinking about thinking, so to speak, and making some assessments of one's self is really helpful in that case as well. Often, because we're dealing with people who struggle to self-assess and they may struggle from a memory standpoint, it's helpful to have evidence that they can review that's a little bit more tangible. That's why part of my research work is in the area of video self-modeling or sometimes, it's referred to as interpersonal process training. The idea is that if I say, "You're chewing your gum really loudly," it's human nature to kind of reflexively say, "No, I'm not, I don't do that," or for that person to have difficulty identifying when it happens, but if they can see it happen, often seeing is believing, so I can say, "Here is the video." They say, "Oh my gosh, I didn't realize I was doing that,x or "This really work well when I did X," whatever that happened to be. So that can be very supportive.

Sucheta: So you are recommending a lot of what we call metacognition, that means awareness of self and awareness of strategies and awareness of implementation, awareness of mistakes. Can you talk a little bit about that benefit of this kind of taking a look at one's self and using that knowledge to produce better outcomes? Isn't that an executive process?

Dr. Hoepner: It is, so there's good evidence to say that kind of an approach works even if it is based on just free recall from that person in terms of what they did and how they performed, but you're right, that's a challenging thing to do for people who have executive dysfunction and memory problems. So having those tangible images, those video images of how they actually performed gives them some more ability, at least we believe, that gives them more ability to make accurate assessments and more often or more frequent assessments, I should say. Ideally, we want them to see themselves doing it right. So if I kind of dip my foot into a pool of neuroplasticity, one of the things, and that always scares people off when you say terms like neuroplasticity, but one of the things we know that is if people follow through with any action or behavior accurately and errorlessly, the more times that they can do that, the more adaptive neuroplasticity we get, right? So the more participation and in particular, the more accurate participation, the better. So in the case of this video review, that gives them the ability to say, "Oh, boy, it really helped when I did this," or "I really started to struggle when this happened," because outside of that practice, they can start to implement those kinds of changes in their everyday behavior.

Sucheta: And I use that technique a lot. In fact, I do not only in-session video recording and watching, and critiquing one's self as homework assignment, but we do that in reverse, that taking a video of yourself at home, and then bringing that video and submitting, when I do group training, submitting that video to the peers and the peers evaluate your performance and kind of having a self-assessment and feedback loop strengthening process, and I find that works really effectively particularly even when the patient does not have the best insight. They begin to speak the language of "I don't know" which is the first step of accepting that behavior exists is a good step to making a progress. So as we come –

Dr. Hoepner: Can I comment?

Sucheta: Go ahead. Yeah, yeah, go ahead.

Dr. Hoepner: Can I comment quickly on your idea of bringing those videos from interactions or activities at home? That's so powerful because now, they're seeing things that really are meaningful because they happened within that community context. That's really valuable when we can pull that part of home into our sessions because now, we are dealing with something that we know is real.

Sucheta: Yes, yes. and another thing just quickly, a lot of times, there is a great resistance to video recording as many of my patients resist or get annoyed with it, so right off when we start the treatment, I make them sign a contract that they will be videotaped and other people will be videotaping them, and so anytime I get resistance, I pull that contract out to show them that they agreed to it because if the mom is recording the sun while he's doing his homework, he gets really annoyed at his mom but then she can say, "Well, you agreed," and that also kind of acts as "Oh, okay," because at the time when they agreed, they don't really have a clue of how it is going to feel like but part of that readiness and slowly kind of training people to accept feedback in multiple settings can become a very effective tool as your research shows.

So Jerry, as we come to a close, I wanted to quickly ask you, in your experience and in your work with many client, what role do you think family can play in helping the patient cope as well as they themselves create an environment where it becomes a collective effort of all to help the patient regain skills and become most productive as possible?

Dr. Hoepner: I really like that way you phrased that question because it brings up something really meaningful to me in terms of my work. I am highly influenced by the work of Mark [28:01] and one of his principles was this idea that collaborative rehabilitation happens with everyday partners, everyday stakeholders and people, and that they are the experts and that they are the ones who are going to be in that context with the person with a brain injury or stroke, or whatever developmental executive dysfunction may be occurring, but they have the insights that we wouldn't necessarily have, so absolutely training them gives us more validity, more value in terms of being real-life activities just from the get-go because now, we have better insights into what happens at home or what happens in the community, and we can equip those partners or those stakeholders with tools that will help them to facilitate better interaction. Based on [28:55] who is from Australia in some work that I've done, we know that good partners not only facilitate successful interactions for persons with brain injuries within that partnership, the two of them, but that expands to other partners and we believe that's because they learn how to interact in those contexts with their supportive partners, and then they carry over some of those techniques outside of that situation. So those everyday partners, if they know how to modify the environment to put fewer demands on someone, then that person can be more successful, and the more successful or accurate, or errorless that person is, the better those interactions support their recovery. My dad always used to say, "Practice doesn't make perfect; it makes permanent," and that's this idea that if you're doing the wrong – if you're practicing things incorrectly, you are producing maladaptive change, but if you're doing it right with a supportive partner who is going to make sure that you get it right more often than not is going to produce some meaningful change.

Sucheta: Oh, what a great way to end this interview. Thank you so much for bringing your expertise and giving your time. I am so grateful.

Before I let you go, if people want to get a hold of you or find out more about your work, what do you recommend they do?

Dr. Hoepner: They're welcome to email me, and my email is hoepnejk@uwec.edu.

Sucheta: Once again, thank you so much, Jerry.

Dr. Hoepner: Thank you for this opportunity.

Producer: Alright, we're back. That was Dr. Jerry Hoepner, our second conversation with him. Wow, great conversation, Sucheta, they always are. Give us a quick rundown of some of your initial thoughts please.

Sucheta: Thank you, Todd. The first takeaway is that to manage executive function challenges after a brain injury, particularly since Jerry and I were talking about that, we need to diagnose or evaluate the impaired abilities or skills, and the demands on performance by identifying where the skills are being put to use, and in other words, where is the individual's bulk of interaction happening in the world? It needs to be investigated.

We speech and language pathologist are truly experts at functional assessment which means teasing apart the context in which the individual with the traumatic brain injury is expected to function optimally, adaptively, and consistently. Is the individual able to keep up with the demands of multifaceted life or is he failing to do so? Those are the kinds of questions a strong and experienced speech and language pathologist is very good at, so the evaluations should center around artificially inducing real-world scenarios and real-world demands, so individual's capacity to endure the challenge or demands will give rise to observable and measurable behaviors which eventually will help become the foundation of therapy. So functional therapy is designed by saying, "Where is it that you need these skills in the most and let me create an environment which mimics your real-life need, and then once you practice it here safely with me, then you can take it outside." A successful evaluation of executive function is such that a testing doesn't eliminate the real-life demands and measures the actions and behaviors meaningfully at the point of impact while the individual is doing the real-life problem-solving, and so that is what is often missing in those who serve people with concussion or traumatic brain injury, or those with even developmental needs in the area of executive function because a therapy situation or being in a session with a clinician kind of eliminates the need of having to do that on your own.

Producer: Well, at the top of the show, you did reference John Cox's story and shared about what got him back on his feet was kind of the rehabilitation, so for those listening who don't know the full extent of what that is, please explain it to us.

Sucheta: Yeah, so I wanted to kind of take a minute to just give you like a theoretical definition, and then even John Cox's the rehabilitation was done by physical therapist which is not the way it is done, but so cognitive rehabilitation is defined as a systematic functionally-oriented service or therapeutic activities that are based on evaluation and understanding of the relationship between brain and behavior of a patient's presentation. So the principles of cognitive rehabilitation are very much rooted in the belief that skills can be trained and must be taught explicitly and systematically. In my practice, I set up the goal in such a way that the clients work towards answering the following questions. You know, the first one is, am I performing at my best? If not, why? Second is, what are the barriers that prevent me from being my best? Third is, what skills do I need to build to circumvent current and future barriers? And the last one is, how can I take that success here in the session to the outside world? A good clinician is really, really strong at creating this transition from observation to outcomes. That is what she designs as a functional therapy circumstances.

Specific interventions may have various approaches. So for example, the first one is, if there's a severe setback after the concussion or brain injury, the treatment needs to focus on reestablishing previously learned patterns of behavior and if the symptoms or setback is not that severe, then the cognitive rehabilitation can focus on strengthening weakly-held habits or skills and reinforcing them with deliberate practice.

The second thing cognitive rehab can do is establish new patterns and provide activities that allow the patient or client to engage in compensatory strategies, so if I'm not, let's say if I can't see, using glasses is a compensation. If I don't remember a discussion, then I carry my tape recorder. If I don't understand a discussion, then I take notes. So those kind of things are compensatory mechanisms.

The third thing is establishing new patterns or completely new ways of doing things that may not be innate or natural to that person, so for example, I work with people who never have made a grocery list because they just say, "I do it in my head," and now, after a concussion or brain injury, they find that they don't remember. They go into the grocery store, they buy two, three things, come home, then they have to make at least two or three trips again, so they are very resistant to using a grocery list, and so that is an external compensatory mechanism but it's artificial. It's very intentionally learned.

And the last thing is the kind of doing all that we can to really help people adapt to the cognitive disability which is kind of, as I mentioned in the top of the show, that there is something literature that talks about which is shakened sense of self, that I am not the same person I was in that kind is very traumatic to people and there is a resistance, it's almost like a beauty pageant winner wanting her beauty back at 50. No, you have to kind of say, "I am a wonderful beautiful version of me but I'm older. I cannot compete myself with a 21-year old." So if you bring that attitude towards your rehabilitation and say that, "Yes, my brain is still beautiful and it's very vibrant. It's extremely capable of learning new skills, I'm just not exactly the same way I was," does it make sense?

Producer: Yeah, yes, Sucheta, it makes perfect sense. It's fascinating stuff, but after a trauma to the brain, there's obviously real changes in someone's basic cognitive, emotional, behavioral skill, right? So to recover or to get better, I mean, they have to get help to change their ways and get through this, yes?

Sucheta: Yes, absolutely, so the hallmark of cognitive disability after a traumatic brain injury is reduced efficiency of approach, slower pace of response or engagement, lack of persistence or grit, and failure to adapt to novel or unfamiliar problematic situations, and what stands out the most is the real disconnect between true capacity and the outcomes of activities of daily life. There's a real disjointedness in daily life and that kind of throws people off and that inconsistency of performance right where the routines happen can have devastating impact because people just take routines for granted, and routines really are the largest source of conservation of energy, cognitive energy, so those who operate without routines really are consuming a lot of brainpower to manage just daily demands.

Cognitive rehabilitation services need to be directed towards achieving changes that impact one's functional aspect, as I mentioned, and that functional aspect is really, there's no point working with somebody's memory skills if that person has no reason to really kind of memorize new material. I mean, the way a student who's learning Spanish who needs to memorize new vocabulary is a different kind of demand than somebody who just works at, let's say at his job in the capacity where he is processing checks and there's nothing new to memorize but the processing checks requires a lot of attention to detail. So the therapy needs to be tailored based on the functional context, as I was mentioning earlier.

And the last thing is that most of this therapy needs to offer respite; it needs to give a break to the person from that neurocognitive impairment and disability, and often, if people don't do that, then your learning skills but your life is not getting better, and that really is not what effective cognitive rehabilitation should be.

Producer: Interesting, so before we close, Sucheta, any final thoughts to share?

Sucheta: You know, to sum up from my conversation with Dr. Hoepner, cognitive rehabilitation needs to address language and cognition. In terms of language, there are many things that one can benefit from learning or finessing which is reading comprehension, spelling, math ability, language formulation, and speech production, but from cognitive intervention point of view, lots of focus needs to be on attention training, strengthening memory, focusing on word retrieval, comprehending abstract concepts, ideas, linguistic nuances, organization, and problem-solving.

Finally, the third part has to be there which is developing insight into one's cognitive strengths and weaknesses, and then one needs to have these compensatory strategies that are built around it, and what I find from executive function training that when clinicians are designing therapy, it is their idea and if it is your idea that your executive functions went into it, so if you want to really cast a change in somebody's life that eventually, you need to equip them to know how to create compensatory strategies for self, and if the work doesn't happen in that area, these people really don't find a long-lasting success.

So that is what I would say is really, really important part. So as I close this session, Todd, a few things about the brain that people need to keep in mind, that there is no difference between a person with a brain injury except one inch is what I used to say to all my patients, that what makes you get a concussion in a fender bender and somebody falling on the ice and hitting their head, or somebody, a garage door for example – I had a client who a garage door fell on her head, those are kind of real life situations that they are not necessarily preventable, they are just part of living, and important part about that kind of concussion and traumatic brain injury to remember is brain injury affects people in different ways. Two people with a concussion do not appear to present themselves in the same way, but most important, focus needs to be how to help people relearn the rules of life. The focus needs to be on teaching them to put the intentional effort in. And finally, we need to teach how to appraise the context in which they need to operate, and that is where a speech and language pathologist or somebody like me and Jerry are really good at. We can make it all really relevant and contextually sensitive, and that's when a patient is going to have a very successful life.

Producer: It must be such fascinating and rewarding work, and challenging in a good way to kind of solve these riddles because as you said, every situation is a bit different, so it must make it fascinating work, and it's a lot more than just putting Tabasco on someone's food, so as we already discussed.

Alright, that's it for today's conversation. I'm behalf of our host, Sucheta Kamath, and all of us at Cerebral Matters, thank you for tuning in today and we look forward to seeing you again next week at Full PreFrontal.