NEUROPSYCHOLOGICAL REHABILITATION

Suggestions/Techniques for Assisting CFS Patients

Neuropsychology - "A science that seeks to combine observations on behavior and the mind with the structure, functions and abnormalities on the brain and nervous systems."

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"How to help those patients who have limited abilities"
(which can vary from patient to patient)

Impaired Alertness and Mental Fatigue

1: Since many patients experience mental fatigue, the need for frequent rest periods is necessary. Often times, the patient may need a 5-to-10 minute rest period per hour or more, and such should be taken. During these rest periods, the patient needs to remove him/herself from the work setting, engage in a period of "daydreaming" or just put up their feet, close their eyes and drift away for a few minutes.

2: It is very important not to be overstimulated -- with too much activity going on. Confusion often accompanies impaired alertness and mental fatigue. Keep all additional stimuli (i.e., the radio, television etc.) to a bare minimum.

3: Many patients experience better performance and are more alert during certain periods of the day -- some are better in the afternoon and some are better in the morning. Try to determine these predictable periods of increased alertness and schedule activities around these periods. From my experience, early in the morning and late in the afternoon are not good times for alertness.

4: Many patients respond better to one sensory mode than to another (i.e., vision, hearing, smell, touch or taste). Find out which is the most effective for the individual patient and use this mode to accomplish tasks.

5: Expect variability! A patient's level of alertness can vary from one day to another (we all have good and bad days). Do not become upset if the patient is not as alert today as he/she was yesterday.

6: Use of long-term interests/hobbies can be very helpful in increasing a patient's alertness. Gradually, by engaging in "liked" behaviors, the length of alert time can be increased.

Deficits in Sustained Attentional Capacities

1: Variability is the rule -- not the exception. Do not expect a patient's attentional capacities to remain constant every day as there are many factors which will affect this capacity.

2: When giving instructions to someone with impaired attentional capacities, be sure that you have that person's attention before giving them the instruction. Say their name, touch them on the arm, etc., to make sure that they are looking at you and can hear your instructions. Following giving them these instructions, ask them to repeat the instructions back to you for clarification.

3: To increase someone's attentional capacities, begin with routine, "liked" and desired activities -- then very gradually increase the introduction of more novel/new tasks.

4: Use demonstrations of activities that you want the patient to perform. Follow the simple routine of telling them what you want them to do, demonstrate it, and then question them for understanding.

5: Use verbal praise and other reinforcers to increase the frequency and duration of desired attentional behavior of the patient.

6: Distractions must be kept at an absolute minimum! Patients should not, for example, attempt to read with the radio on or attempt to balance the checkbook while others are in the room talking. ALL OUTSIDE DISTRACTIONS should be removed.

7: Start out with tasks that are easily within the ability of the patient. Do not expand the amount of stimulation until the patient can handle it.

8: Watch for signs of mental fatigue and suggest necessary rest breaks.

9: Encourage telephone conversations to increase attentional capacities. By talking on the phone, the patient has a reduction in the amount of stimuli coming into the brain (they are only hearing the other's voice) and gradually increase the amount/length of such conversation.

10: Break down ALL tasks/activities into sequential (step-wise steps) and focus only on step #1 until is is successfully completed before moving on to step #2.

11: When necessary, provide cues to the patient regarding what sequential step they were last on, in order to keep them on task.

12: "Dove-tailing," or the notion of engaging in 2 tasks simultaneously, should be avoided.

Mental Confusion

1: To reduce confusion, reduce the amount of stimuli going on around the patient. For example, do not drive with the car windows down, the radio on, etc. Roll the window up and turn off the radio so as to reduce the confusion and focus on the task at hand.

2: Develop a routine where the patient knows what to expect. If possible, get up at the same time in the morning, develop a routine of getting dressed, eating, and then develop a routine of daily activities. By having such a routine, the unexpected can be reduced and the patient's level of functioning, with reduced confusion, can be facilitated.

3: Always explain fully, to the patient, what you intend to do before initiating behaviors. Such can thus reduce the unexpected.

4: In general, confronting the "inappropriate" behavior or mental confusion in the patient will not be effective. Instead, REDIRECT the patient into alternative actions or redirect them back on target.

5: Continual repetition is a key factor in reducing confusion. Now is not the time for a patient to attempt to change jobs or learn a new aspect of a job. It is very important that, until the confusion has begun to reduce, the patient keep doing what he/she has been doing over and over again.

6: For example, many individuals with head injuries tend to wake up more slowly and are slightly disoriented. If disoriented, allow extra time in the morning for them to get up. Let them lay there in bed for a few minutes, so as to enable them to reorient themselves, before rising.

7: The use of wall charts, appointment books, calendars or other tools that will assist them in orientation can be very helpful.

8: Model calm, quiet and confident behavior for the confused patient. The more confused and agitated the patient becomes, the more calm you should be. Then redirect them back onto the task or divert their attention from the source of confusion.

Impaired Ability to Carry Out a Plan of Action or Sequential Thinking/Actions

1: It is very important to BREAK DOWN ALL BEHAVIORS INTO THEIR LOGICAL AND STEP-WISE SEQUENTIAL BEHAVIORS. Virtually everything that we do is done in steps. Taking a shower involves many steps in order to be completed successfully and think of the possible consequences when one step (i.e., taking off clothing) is omitted. The patient needs assistance in viewing everything in this manner. It may be necessary to begin by writing out the steps of different tasks to assist them.

2: ONLY focus on step #1 until it is SUCCESSFULLY completed. DO NOT advance on to step #2 until step #1 is consistently done correctly. For example, balancing a check book requires many sequential steps. It may be only possible for the patient to complete step #1, and someone else may be required to complete the process. If this is the case, allow the patient to sit and observe, and the other person should explain these subsequent sequential steps as they proceed.

3: There are various computer games which require such sequential thinking, and can be effective aids in this training.

4: "Dove-tailing," or the notion of engaging in two tasks simultaneously, should be avoided.

5: It is often helpful for the patient to become somewhat "obsessive-compulsive" in nature. By this I mean that by becoming very organized, it reduces confusion and facilitates the patient's level of functional abilities.

Memory Deficits

1: Try to pair new learning with old, familiar concepts that the patient is able to recall. This pairing can often enhance the coding process for more recent events. For example, if you want the patient to recall where he went to eat last night, cue him as to the type or kind of food he ate (i.e., Italian) and/or that this particular type of food was a favorite of his.

2: Teach the patient to WRITE DOWN EVERYTHING. Obtaining a snall spiral bound notebook or some other form of paper that the patient can write down all important facts, etc., that can be easily viewed and retrieved.

3: Frequent cueing and rehearsal of new information is a must.

4: It is often easier for an individual to recall something when they write it down using their own words than if someone else is to write it down for them.

5: Not only tell the patient what he/she is to recall but demonstrate, if possible, what is to be remembered.

6: Use of wall charts, appointment books, etc., are very helpful in facilitating memory.

7: Use music to facilitate recall. (After all, can't we all recall the words to those songs better than we can recall events of yesterday?)

8: Suggest that the patient develop little funny strategies to help remember items. For example, if I want to recall the number for a personal banking machine, I will develop a funny little saying about those numbers (i.e., "I will be 68 when she will only be 17").

9: Do not believe the patient when you are told, "I know that." Be sure that you "check it out" that the patient does understand the information and is able to follow through.

10: The use of imagery (attempting to create a mental picture) to recall some specific information is also very helpful. For example, the patient may recall a grocery store list, by forming a mental picture of the meal prepared and setting on the table.

11: Another technique that is often helpful with memory problems is that of lumping or grouping of the information to be recalled. For example, with this same grocery shopping list, the patient could group all of the items into categories (i.e., breads, fruits, etc.).

12: The use of the technique called the SQ3R is often very helpful when attempting to facilitate recall from reading materials. The specific sub-components of this technique direct the patient to:

SURVEY: Read the key headings, titles, etc., to form a general impression of what this material will be about.

QUESTION: Develop a list of questions (I usually recommend writing down the questions) that the patient will attempt to answer from reading the material.

READ: Read the article, book or whatever.

RECITE: Recite the key components (in the patient's own words) of what was just read and answer the generated list of questions.

REVIEW: Review the reading material all over and attempt to verbalize what was just read.

13: When reading, encourage the patient to read out loud. By doing this, the patient will actually be encoding the material three different ways (through seeing it, through saying it and through hearing it) and thus will have a better chance of recalling the material.


Information for this text is from the brocure, "Neuropsychological Rehabilitation." Material compiled by:

Dr. Dennis G. Cowan, M.D.
17203 E. 23rd Street
Suite 200
Independence, Missouri 64057

This text prepared and provided by:

National Chronic Fatigue Syndrome and Fibromyalgia Association
P.O. Box 18426
Kansas City, MO, USA 64133
(816) 313-2000

(Text may be reproduced and/or distributed provided sources are credited.)

Web page design by Bill Jackson, 1996.

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