SAC Profile: Cameron Mang & Brain Power Hour

We are incredibly grateful to the members of our Scientific Advisory Committee for their support in developing evidence-based information for the brain injury community. They are doing great things in their respective fields – like Cameron Mang. As a practicing Kinesiologist and Certified Exercise Physiologist in the field of Neurorehabilitation, Cameron conducts research with real-world implications for people with neurological conditions. He is an assistant professor at the University of Regina, and has developed crucial links between research and community programming, fostering knowledge mobilization. Recently, he shared details of a community program Brain Power Hour.

There is a need for safe community programming for people with brain injury to address secondary impacts of the pandemic. The “Brain Power Hour” program manual will support expansion of low-cost exercise and recreation programs in Saskatchewan

After a brain injury, people experience many life changes, including losses in physical function and decreases in socialization and mental health. Rehabilitation after brain injury often ends within about three years  from the injury, and people are not always able to maintain or build on the gains made in rehabilitation, sometimes regressing. The purpose of this study was to develop an outdoor exercise and recreational walking program and study its impact on the lives of people in late stages of recovery from acquired brain injury.

The “Brain Power Hour” exercise and walking program was developed and implemented with members of the Saskatchewan Brain Injury Association (SBIA) in Regina, Saskatoon and Moosejaw in the spring and summer of 2021. Across Saskatchewan, 22 program participants consented to be involved in the study. Participants attended up to two, one-hour weekly group exercise and/or walking sessions. A researcher and program facilitator conducted interviews with participants in Regina during program delivery. Program facilitators recorded field notes describing notable experiences with the program.

Interview findings suggested that many people with acquired brain injury are not able to exercise or participate in recreation independently due to functional challenges and safety concerns. Individuals commented on the COVID-19–related disruption of therapy and community programming, which contributed to functional challenges, loneliness, and decreases in well-being. Interview responses suggested that the “Brain Power Hour” program provided a means to mitigate these negative impacts by providing physical and social benefits.

This project was made possible by the Saskatchewan Brain Injury Association (SBIA) and was funded by the University of Regina Community Engagement and Research Centre – ‘Community Research and Action Fund”. Student funding for Ms. Jeannie Postnikoff was provided by the Saskatchewan Centre for Patient-Oriented Research.

SAC Profile: Dr. Amine Choukou & The Active at Home Post-Stroke Program

Profile picture of Amine ChoukouOur Scientific Advisory Committee is comprised of professionals in the research and medical practice sectors that work to support the brain injury community. One such individual is Dr. Amine Choukou.

Dr. Choukou’s research focuses on delivering telerehabilitation services to people with chronic stroke, Parkinson’s disease, and multiple sclerosis who live in the community. Innovative technology fills in many gaps in the current practice and promises a better access to care for all, regardless of their geographic location. Receiving rehabilitation care at home is at the utmost of the needs of people living in rural and remote communities who want their physical or cognitive skills recovered or improved. Ultimately, these technologies are intended to help these individuals live independently with dignity.

“I dedicate a considerable portion of my research career to brain injury because I see people leave institutions without their needs being met, and I believe that home telerehabilitation is a smart approach to bridge that gap, while promoting autonomy and independence.”

Dr. Choukou’s efforts in telerehabilitation is demonstrated in an on-going project that is as of May 2022 in the test phase.

Active at Home Post-Stroke Program (Home PSP) is designed to provide stroke survivors with comprehensive physical and cognitive rehabilitation. The program provides semi-supervised at-home telerehabilitation to patients living in rural, remote and underserved areas who could not access rehabilitation services otherwise. The importance of remote health technology has become even more clear in light of recent COVID-19 restrictions; telerehabilitation has never been more relevant.

Home PSP delivers telerehabilitation via three easy-to-use technologies shipped to the patient’s home:

  • A mobile app
  • A virtual reality (VR) system
  • iManus

The interactive mobile app provides guided physical rehabilitation through an Android tablet. A virtual coach delivers an exercise program that includes resistance training, balance training, and stretching.

A simulated VR environment provides physical and cognitive training activities for patients to complete. With VR training, the patient benefits from continuous and safe practice, at their own pace and in the comfort of their home. The patient begins by performing simple domestic activities, and advances up to unexpected and complex situations.

iManus (www.theimanus.ca) is a patented technology developed under a partnership between the University of Manitoba and Tactile Robotics Ltd. iManus consists of a pair of sensorized gloves and therapeutic equipment for manual dexterity training. A mobile app interface collects data from the gloves and connects the patient to a therapist.

The goal of Home PSP is to help patients regain their physical and cognitive abilities following a stroke. The activities resemble scenarios we encounter during daily life, and the therapeutic content has been validated by therapists. The needs of stroke survivors vary widely, and Home PSP is designed with this variety in mind. A therapist offers personalized guidance at a distance based on data collected with the different technologies that make Home PSP. The program is underway in Manitoba, and contents can be adapted for patients with traumatic brain and spinal cord injuries.

For some, at-home telerehabilitation allows them to receive structured therapy that they would not otherwise be able to receive. Many people will benefit from this program, which reduces family burden by limiting travel and indirect care costs.

Music Therapy

Music is processed in all parts of the brain (Sacks, 2007). For someone who has had a brain injury, music may be helpful in providing cognitive stimulation, motivation for movement, and emotional and/or spiritual support.

Remember: Brain injury is complex: every situation is different. This means that everyone will respond differently to music & music therapy. Please speak with your physician and the nearest music therapy association for information most relevant to you.

Neurologic music therapy (NMT)

In some cases, neurologic music therapy (NMT) may be helpful as a rehabilitation and recovery tool. Neurologic music therapy is a specific training focused on the use of music and musical elements to motivate and target change (neuroplasticity). It is often used in connection with specific goals that an individual, general practitioner, and/or multi-disciplinary team have identified. These goals could be related to physical movement, communication, cognition, or emotions.

Here are some examples of how neurologic music therapy can be used for different types of goals.

Music therapy & physical independence

If an individual wants to improve their uneven gait (how they walk), live music can be used to motivate them to take more coordinated/even steps. Rhythmic music and different chord progressions engage with the motor cortex of the brain (Alashram et al, 2019). It’s similar to people wanting to dance to certain beats and rhythms.

As an individual improves their gait pattern, the music is gradually taken away. Eventually the goal is for the person to be able to show improved gait without the music.

This same process is applied to most goals associated with activities of daily living (ADLs).

Music therapy & improving speech

Music can be used by individuals who want to improve their speech clarity, tone and/or volume. A neurologic music therapist will use techniques to encourage lip movement; improve soft palette sounds; strengthen diaphragmatic breathing; and improve pitch and volume control.

It’s not about getting the perfect note or singing voice; it’s about using music as an enjoyable and engaging medium to help with speech. The added benefit is that singing is fun and can help build a person’s confidence as they practice.

The music is then taken away with the goal of having the skills carry over in everyday communication.

Music therapy & cognition

For an individual who wants to improve their visual neglect and/or attention span, a neurologic music therapist may apply techniques to target change for these specific goals.

For example, if someone wants to improve their visual neglect, the use of music scales and chord sequences may be used as an auditory prompt to remind someone to look towards their neglected side. If someone wants to improve their attention, a certified music therapist may use different music therapy interventions to prolong attention or practice divided attention.

Music for mental health & well-being

Music is a part of the human experience that tracks back to prehistoric times. Music forms part of an individual’s identity. People listen to music to relax, to exercise, to process emotion, and to spiritually connect. Music can also be associated with powerful memories.

When choosing music, it’s important to ask the following questions:

  • What kind of music do you prefer?
  • What music is familiar?
  • What did you listen to growing up?
  • What music connects to which emotions?
  • What music reminds you of specific memories?

When chosen thoughtfully, music can improve mood and support mental health and well-being.

Accessing music

There are many ways to access music. Many people have existing music collections – this can include records, CDs, or digital downloads.

Some additional examples of accessible music resources include:

  • CDs at the library
  • Spotify/Apple music playlists (precomposed or customized). Please note these are paid platforms
  • YouTube playlists (precomposed or customized)
  • Local performances within your community

More information about music therapy

References

Alashram, A.R., Annino, G., & Mercuri, N. B. (2019). Rhythmic auditory stimulation in gait rehabili-tation for traumatic brain and spinal cord injury. Journal of Clinical Neuroscience, 69, 287-288. doi: 10.1016/j.jocn.2019.08.080

Sacks, O. (2007). Musicophilia: Tales of music and the brain. New York: Alfred A. Knopf.

Content for this page provided in part by Bernice Chu, MA, NMT-F, MTA. Bernice is a certified music therapist currently working with adults who have experienced brain injuries, burns, trauma and long-standing mental health needs. She is the secretary for the Music Therapy Association for British Columbia. 

Exercise after brain injury

Many people may be nervous to try exercising after brain injury in case they make their symptoms worse. But when you start slowly, complete your exercises safely and listen to your body, it can have a lot of benefits for your brain health. This is the reason many health professionals make recommendations for physical activity as part of a brain injury recovery plan.

Please note: You should always consult with your doctor or primary care physician about what exercises are appropriate for you. Not all exercises or exercise programs will be safe or effective for you.

The benefits of exercise after brain injury

Improved mood

Regular exercise that increases the heart rate can cause the release of serotonin and dopamine, which help alleviate feelings of depression [1]. Endorphins from exercises are also associated with improved mood [2].This means that exercise can actually help make you feel happier.

Support for brain healing & function

Studies into the effects of exercise on brain injury survivors have shown that individuals with traumatic brain injury (TBI) who exercised, had fewer cognitive, physical, and emotional symptoms [3]. Additional reviews of existing studies demonstrated that physical exercise also has a positive effect on cognitive functioning [4,5]. This includes thought processing and memory. According to research [6], the physiological factors of exercise that contribute to improvements in cognition include:

  • Increased blood flow to the brain
  • Changes in the brain involved in cognitive behaviour

Support for bodily health & well-being

The main purpose of exercise for the majority of people is to improve their physical health. Different types of exercises can strengthen the heart, lungs, and muscles. It’s an essential building block for a healthy lifestyle.

Exercise comes in many forms – you don’t have to be at the gym to be healthy, and you don’t have to exercise for hours at a time. The health benefits come from being consistently active in your day to day life to the best of your ability. Walking or stretching can be as beneficial as strenuous activities: it’s all dependent on what your body is able to do and what it needs.

The challenges of exercising after a brain injury

After a brain injury, you may face some challenges when it comes to exercise:

  • Changes in physical capacity and mobility
  • A lack of motivation, interest or energy
  • Symptoms such as fatigue and headaches that may impact your abilities
  • A lack of access to appropriate physical rehabilitation, exercise space or appropriate equipment
  • Not enough support

While these definitely are challenges, that does not mean it’s impossible for you to exercise and receive the benefits. It just means that you may have to get creative.

Physical rehabilitation

Physical rehabilitation (physiotherapy) is one of the most common therapies for people of all abilities. It can be helpful for people with brain injury who are experiencing challenges with mobility, strength, balance, and cardiovascular fitness. A physiotherapist will perform an assessment and work directly with you to develop a treatment plan based on your challenges and your goals. The treatment plan will largely consist of exercises or physical motions that will be modified to your needs so that you can replicate them at home. It may be recommended that you continue the exercises at home to the best of your ability either on your own or under someone else’s guidance.

There are both private and public physiotherapy practices, and you may be covered for some of the costs through your provincial/territorial insurance plan, a private insurance plan, or an auto insurance plan (depending on the cause of your injury and type of coverage).

Types of exercises

Aerobic exercise

Aerobic exercise can also be known as cardio: in other words, any type of exercise that strengthens the cardiovascular system (your heart and lungs) [7]. Types of aerobic exercises include walking, running, cycling, or swimming. Aerobic exercises are meant to increase your heart rate, and are done for longer periods of time on a consistent basis.

A 12-week study on the effects of aerobic exercise on depression symptoms in those with traumatic brain injury (TBI) found that participants had higher self-esteem, improved cardiovascular function, and fewer symptoms of depression [8].

Aerobic exercise is often connected to a healthier heart, but it has tremendous effects on body and brain health as well. Check with your doctor to make sure you understand what you are able to do safely for exercise. You may not be able to go for a run, but you could go for a walk.

If you need some extra support for your aerobic exercise, there are assistive mobility devices that may be helpful for you.

Strength & conditioning exercise

For individuals with muscle weakness, strength and conditioning exercises after brain injury can be incredibly beneficial. Types of exercises that can help with strength and conditioning include resistance training, which can include using body weight or using free weights.

The key to strength and endurance training is patience. You don’t want to push yourself too hard or too quickly. Working with a physiotherapist or occupational therapist on a recovery program can be beneficial and help you progress safely.

Range of motion exercise

Range of motion (ROM) exercises can also be called flexibility and mobility exercises. Depending on the physical effects of your injury, you may be experiencing problems with your muscles or joint tightness. The purpose of ROM exercises is to help increase muscle flexibility and joint mobility. With time and patience, these types of exercises can help you move more easily (such as lifting your arms or bending your legs).

Balance exercise

Many individuals struggle with balance after brain injury. Balance is the ability to keep yourself centered.  Specific exercises can help you work on your balance and make you feel steadier as you move through your day.

Remember – any exercise is a gradual process. You may be feeling good one day, and not as great the next. And that is totally normal – the important thing is to take it slow and not get discouraged.


See sources

Types of rehabilitation

Please note: not all of the therapies listed below are available publicly and may not be covered by insurance providers. This means that there may be out of pocket costs, depending on the type of therapy you do.

There are several types of rehabilitation that individuals with brain injuries may find helpful in their recovery. We have included the most common and recognized rehabilitation therapies. Different rehabilitation therapies will be recommended for different people. Not every rehabilitation therapy will be available in every area. Speak with your medical team about rehabilitations available to you, and ways you can access them. In some cases, there may be online rehabilitation services that can make getting support even easier.

You can also reach out to your local brain injury association about available public groups.

Occupational therapy
Occupational therapy (OT) assists with activities of daily living (ADLs) and creating a home environment that is designed for the person with a brain injury to be as independent as possible. This includes things like:

  • Cooking
  • Eating
  • Bathing
  • Cleaning
  • Getting dressed
  • Going to the bus stop

After a brain injury, these everyday activities can be more challenging. If you’re experiencing problems with your fine motor skills, having trouble with memory or processing instructions, or have issues with vision, hearing, or touch, occupational therapy will be a big help.

An occupational therapist will perform a functional assessment of you, your family, and your environment. They identify impairments and environmental barriers and create a treatment plan designed specifically for you. Part of the plan is developing specific goals you want to achieve, and using tools and strategies to help you do so. An occupational therapist helps you re-learn self-care, work, and leisure skills. This includes teaching you new ways to do things if your capabilities have changed. Their job is to help you with your ADLs, and help you reach a place where you can do them as independently as possible. They’ll do this using tools, new processes, and activities. They’ll even complete an assessment of your home environment so it can be set up in a way that works best for you. This includes making recommendations for furniture placement and how to remove tripping hazards and prevent further injuries.

Physiotherapy
Physiotherapy focuses on improving movement and mobility. This is done through carefully monitored stretching and exercises. This is one of the most common therapies – most people recovering from physical injuries need it. A physiotherapist is a rehabilitation professional who will perform an assessment of your physical capabilities and create a treatment plan to improve strength, muscle tone, or mobility. Exercises and activities can include range of motion exercises (ROM), strengthening exercises focused on building endurance and muscle, balance exercises which will target areas of deficit, and gait training to improve posture and walking.

Physiotherapy can be short or long-term. You may also be given activities or exercises that you have to do between appointments. As you meet physiotherapy goals, your abilities and needs will be reassessed, and your plan adapted to make sure you continue making positive progress.

Psychological therapy
Psychological therapy – which can also be called counselling – is an excellent way to take care of your mental health and understand more about your emotions, behaviours, and thoughts. It’s also a great way to unburden yourself and receive considerate, thoughtful feedback from a professional. Counselling can be done by either a psychiatrist or a psychologist – both are licensed mental health professionals. The main difference is that a psychiatrist has a medical degree and is able to prescribe medication.

The health professional providing the treatment will first complete an assessment to help identify what you need and what goals you would like to reach.

Speech and language therapy
Possible effects of brain injury include cognitive communication challenges. You may not be able to process your thoughts, have difficulty organizing your speech, or struggle with reading/writing. A speech language pathologist (SLP) can help with relearning communication skills and new adaptive techniques.

A person may also experience difficulty speaking or trouble swallowing. These challenges are connected to the throat and mouth muscles. Not only can it be difficult to talk, but it can be challenging to eat or drink, causing further problems with nutrition and safe eating. An SLP will perform tests in the early (acute care) stages of recovery if a person is experiencing any of these issues. It may be recommended that the person continue to work with a speech language pathologist to improve speaking and swallowing abilities. This can be a long process that requires patience, and treatment will be updated on an ongoing basis.

Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy is rehabilitation that focuses on creating programs and activities that will help you engage in positive and productive behaviour. Cognitive behavioural therapy covers a lot of symptoms of brain injury, including neural feedback, appropriate behaviour, memory, and information processing. Since no two brain injuries are the same, cognitive behavioural therapy doesn’t have a set program of exercises and activities. Your therapist will perform an initial assessment and set goals with you that you will then work towards. Once those goals are met, new goals will be set, and the treatment plan will evolve to include activities that will help you reach those goals.

Cognitive behavioural therapy is becoming more and more common, but it is still a growing part of rehabilitation for brain injury and is not as widely available as other types of rehabilitation.

Vocational rehabilitation therapy
It can be challenging after a brain injury to go back to a job. Depending on your injury, you might not be able to return to your former workplace or you may have to come up with new strategies to help you complete work-related tasks. Vocational rehabilitation therapy focuses on helping you prepare to re-enter the workforce. They give you the tools and skills needed to find a part-time or full-time position. In partnership with the Vocational Rehabilitation Association of Canada, we have developed a guidebook to help you understand the return to work process.

Art therapy
Art therapy is a more experimental therapy. Patients complete art projects in a personalized program. When someone is working on a creative art project, it can stimulate multiple parts of the brain at the same time and encourage neural pathways to form. Art therapy can also improve fine motor skills, help with other cognitive challenges such as memory and attention, and improve mental health and moods. Art therapy is conducted by licensed art therapists and is normally an out-of-pocket expense.
Mindful meditation and yoga
Mindful meditation and yoga have become popular forms of therapy after brain injury. Both focus on the concept of quieting the mind, limiting outside distractions, and focusing on deep breathing and relaxing. Meditation can reduce stress and anxiety and allows for emotional self-check-ins and is a great technique for calming down.

Yoga also reduces stress and anxiety but adds an element of physical movement. Yoga moves are designed to be adapted and taken at the person’s pace. There are special classes and movements designed specifically for people who need adaptations.

Music therapy
Music therapy uses music to help people with functional goals, improve mental health and cognition, and promote self-awareness and reflection. Music can be used to help with speech problems through musical vocals, motor skills through instruments, and cognition through composing. Music therapists are licensed professionals who undergo several years of training. Music therapy is an out-of-pocket rehabilitation expense.

More information on music therapy

Recreational therapy
Recreational therapy uses leisure activities that a person would normally do to meet rehabilitation goals. The goal of this therapy is to help the person become as independent as possible when doing those activities. This could include walking, outdoor activities, arts and crafts, dancing – anything someone would normally do in their leisure time. Certified recreational therapists will use these activities to help with cognition, mental health, and even physical health if the activities are exercise-based.

Additional rehabilitation specialists

Depending on your rehabilitation needs, you may work with additional rehabilitation specialists who will help you with recovery. Please note: you may not need to work with every kind of rehabilitation specialist. Doctors will make recommendations and referrals based on your needs.

Audiologist
An audiologist is a healthcare professional with a focus in hearing loss related to the inner ear and vestibular system. They can diagnose and recommend treatment for people with brain injury who are experiencing hearing loss.
Behaviour therapist
A behavioural therapist is a professional that uses professional training to help people with behaviour challenges understand good vs. bad behaviour. The therapist will identify the problem behaviours, then outline a treatment plan based on what the person wants to achieve. While there are many different types of behavioural therapy, the therapist will help reinforce positive behaviours.
Case manager
A case manager is someone who can help you coordinate appointments and other daily activities after your brain injury, particularly if you are experiencing cognitive challenges that make planning and going to appointments difficult. They can also help you by going to appointments with you and assisting you with post-appointment activities.

Case managers are not available everywhere in Canada and may be an out-of-pocket expense. You should speak with your physician about available rehabilitation specialists in your area and what would be right for you.

Chiropractor
Chiropractors focus on treating neuromuscular (nerve and muscle) conditions by physically working on the person’s spine. Their focus is on improving muscle and skeletal structure and reducing pain in the back and related joints. Chiropractor services can be helpful for people with lingering pain from physical injuries.
Dietitian
A dietitian is a medical professional with a degree in nutrition science. They are able to understand how food impacts health and well-being, and work with individuals to create comprehensive diet plans that treat nutritional problems. Treating nutritional problems can aid in treating other conditions, such as brain injury.

Please note: There is a difference between a dietitian and nutritionist. Dietitian is a protected term in Canada, which means they need to have professional certification. Nutritionist is only a protected term in Alberta, Quebec and Nova Scotia. This means that someone may be a nutritionist in British Columbia but not have the same credentials as someone in Alberta. Dietitians of Canada has an explanation and a chart of protected titles by province/territory that can help you identify what kind of health professional to consult for dietary needs.

Ear, nose and throat doctor (ENT)
An ear, nose and throat doctor (ENT) – officially called an otolaryngologist – is a doctor that specializes in the connected systems in the head. An ENT can diagnose and provide treatment recommendations for conditions such as hearing loss, tinnitus, sinus issues, balance problems, and swallowing difficulties.
Life care planner
A certified life care planner is someone who can help you create a plan after a life-altering event such as a brain injury. This plan can include services, supports, and costs necessary from that point on. A life care planner will perform an in-person assessment and develop a plan that will help map out future needs. This is incredibly helpful, especially if a person’s abilities to plan are compromised, or their family is worried about care, finances, and emergency planning for the future.
Life skills planner
A life skills planner is someone who is trained to teach other people how to develop and improve life skills. Life skills is a broad term used to describe any skills that are helpful in activities of daily living (ADLs). Examples of life skills include communication skills, interpersonal skills, decision-making, and taking care of a home.
Personal support worker
A personal support worker is someone who helps you with your activities of daily living (ADLs) and self-care, and is either with you full or part-time in your home or at a treatment centre. Their role is to help make your day-to-day routine more manageable.
Neurologist
A neurologist is a medical health professional that specializes in treating the nervous system, which includes the brain. A neurologist is one of the physicians that would be able to make a diagnosis of brain injury and address symptoms. They also help with management of brain injury and its symptoms through treatment and referrals to other treatment options.
Neuropsychologist
A neuropsychologist specializes in understanding how the brain and behaviours are linked. For someone with an acquired brain injury, a neuropsychologist can help determine how the injury will affect their cognitive abilities and behaviours and make recommendations for what rehabilitations could be helpful in your recovery.
Physiatrist
A physiatrist is someone who specializes in physical medicine and rehabilitation. They can help a person with a brain injury by evaluating physical needs and making rehabilitation/treatment plans. The physiatrist can identify and make recommendations for treatment in relation to physical, cognitive or behaviours problems that can result from brain injury.
Recreational therapist
A recreational therapist is a professional that uses leisure and recreational activities as rehabilitation to build skills. The treatments are assessment-based and can be useful for people with social, cognitive, and behavioural challenges in developing independence and improving quality of life.
Respiratory therapist
A respiratory therapist is a professional that can assist with breathing difficulties. They work alongside doctors at hospitals to provide emergency respiratory care, or they can work in rehabilitation centres or at home to help people with ongoing breathing difficulties. Doctors will provide a recommendation if they think you need to see a respiratory therapist during rehabilitation.
Social worker
A social worker is a healthcare professional that provides ongoing support to the patient and the family by serving as an advocate and assisting with accessing services. They can also provide some levels of counselling. Their primary focus is improving overall well-being. A social worker can be a huge help for someone who is not sure where to find information or resources or needs someone to help support them while they look for services.

What is neuroplasticity?

Our brain changes in response to things like learning, stress, and injury. It will continue to do this for our entire lives. Your brain may never work exactly the same way, but it will continue to adapt and respond. In research, this is often referred to as neuroplasticity (neu·ro·plas·tic·i·ty).

Neuroplasticity is a highly complex topic, and there is not a lot of peer-reviewed, substantiated research on neuroplasticity and its effectiveness in rehabilitation practices. This is why we have made the decision not to include information on this topic at this time. If you do have questions about neuroplasticity, these should be put to a neurologist or neuropsychologist.

One of the best things you can do to help your brain injury recovery is to focus on brain and body health. When you feel good, eat well, get enough sleep and participate in aerobic exercise, your brain will benefit.

Activity planning assessment tool

Over time, an acquired brain injury survivor may experience some challenges with mapping the progress of their recovery. In some situations, things may seem muddled in together, perhaps creating a sense of distress as it becomes difficult to identify the real progress that is being made.

As individuals evaluate how things are going overall, on a specific activity basis, it can also be helpful to acquire some concrete assessment information.  This data will help to map the gains being made.

The following Activity Planning Assessment Tool can be used as a companion throughout the recovery process.

Objectives:

  1. Track progress
  2. Identify activities that bring positive results overall
  3. Understand how participating in various activities might bring on symptoms
  4. Identify activities that may be challenging, yet overall are beneficial to engage in
  5. Develop strategies to manage symptoms

The first part of this assessment is to build awareness about the types of activities you typically engage in, and to determine how your participation in these may affect you and others.

You can choose to answer these questions by recording your responses, or you can go through the list and make a mental note of your thoughts. You can also discuss your responses with a trusted partner; family member; friend or colleague.

The debriefing questions will bring to light any comparisons, challenges and/or gains that you are making, and will allow you to prioritize which activities you might like to engage in.

Using this information, you can choose to invest your time and energy where you believe is the most appropriate for you at this point in time. It’s important to note that while you may choose not to participate in something now, you may feel like you will want to in the future. With this in mind, the assessment is also a good opportunity to help you to identify these activities for the future.

Building Awareness:

  • What is the activity that I am considering?
  • Overall, is this an activity that I want to engage in?  Why?
  • What positive results might this bring to me?  How will this affect me and/or others?
  • What negative results might this bring to me?  How will this affect me and/or others?
  • Will participating in this activity affect my energy level?  In what way?
  • If this does drain my energy, what are the energy management strategies that I can develop to address this?
  • Is this activity something that I have participated in pre-injury?
  • In my estimation, this is how I will be feeling after this activity
  • In my estimation, the recovery time following this activity will be
  • What is the value that I am contributing to this activity?
  • What value will this activity bring to me and/or others by my participating?

Debriefing:

  • If you have participated in this activity pre-brain injury, how does this time compare overall?
  • What were you aware of this time?
  • How did you feel when you were participating in this activity?
  • In reality, this is how I felt after this activity.  Compare this to your estimate above.
  • In reality, this is the recovery time following this activity.  Compare this to your estimate above.
  • Were there any specific symptoms brought about as a result of engaging in this activity?
  • At what point, if at all, did you begin to feel your energy drain?
  • What do you believe contributed to this?
  • Describe specifically how you knew your energy was draining/what was happening?
  • What did you do?
  • If you pushed through it, what happened next?
  • Describe any gains, no matter how small or big that you experienced.
  • Did you receive any comments/feedback/encouragement from others either prior to, during or following the activity?  What were they saying?
  • Did participating in this activity give you any confidence?  In what way?
  • What, if any adjustments could you make in order to improve the results for next time?
  • Would you participate in this activity again in the future?
  • On balance, is the activity worth your time investment and engagement?

Back-up Plans and Developing an Exit Strategy

  • Part of deciding to engage in an activity will depend on whether you have a back-up plan and/or if you have an exit strategy developed. Following are a couple of examples of this.
  • Rather than commit to attending a full event, perhaps you can agree to attend on a reduced timeframe. This plan balances out having to take an all or nothing approach. You are signaling that you are interested in attending, yet at the same time you may not be able to manage the full event and the potential sensory overload.
  • If you would like to attend a concert or a ballet – but you are not certain if you can sustain the energy required, or manage the sensory stimulation – have an exit strategy pre-arranged. Tell your partner or whomever you are attending the concert with that you would like to experiment by attending. However you may not be in a position to remain for the full concert. On a pre-arranged signal, should you need to leave, you can exit the concert when suitable.
  • For pre-planning, when you purchase your tickets, plan to sit on the end of a row. This way, you will know that you are not disrupting anyone should you have to leave.
  • If attending a movie, plan to arrive just as the movie begins. Avoid the trailers as they can be noisy and visually disturbing. Pre-plan as much as you can. Step out if you have to. Try this out to see how long you can stay in a movie theater. In the beginning, attend a quieter movie and build from there.
  • Go to the concert or movie prepared, bring sunglasses, earplugs or other noise dampening devices.
  • If you normally bowl three games, if you feel ready – try one game.
  • Sudden energy crashes can occur. To the extent possible rest or sleep prior to attending an event. On the way there, reduce any noise and/or distractions. Remain as calm as possible and connect to the positive aspects of taking this step.
  • If you are somewhere alone and you need to leave unexpectedly, always have a back-up plan developed. Whether this is a pre-arranged ride that you can contact; money on-hand for a cab or a ride-share, it will be important for you to know that you will have some support with returning home. This step will give you confidence as you begin to experiment with re-engaging in social and/or other activities.

The benefits of pre-planning are far reaching:

  • Opportunity to experiment with re-engaging in social and/or other activity; assess and adjust as may be required for the next time.
  • Maintain control over the factors you can control – and on your own terms.
  • Allows for energy mapping strategies to work in your favor.
  • Brings enjoyment and fulfilment back into your routine.
  • On a holistic level, it will balance out your overall outlook.

 

When nothing seems to be working

You feel like you have tried everything. You doctor says you are doing all the right things, but you are still experiencing debilitating symptoms with no relief in sight. This can be frustrating and make you feel a sense of hopelessness.

While there is no magic spell that will make you feel better, there are a few options to explore.

Seek a second opinion

It is within your right to seek medical care from a variety of professionals. Some may have different training or more up to date knowledge on brain injury (or brain injury-related medical topics).

Allied health professionals

Allied health professionals are healthcare and health service providers that are not specifically medical-focused Allied health professionals include: dental hygienists; laboratory and medical technicians; optometrists; pharmacists; physio and occupational therapists; psychologists; speech language pathologists and audiologists . They can provide a range of diagnostic, therapeutic, and support services to aid in your treatment and recovery.

Ask your physician about the benefits of other therapy options.  Some of these services do not require a physician referral, so be sure to do your homework. Please read the next section on Private Clinics for additional information.

Private clinics

The public health care system can be limited and not cover all treatments and services.  You may need to seek the assistance of private providers or clinics. Be mindful that some of these clinics are not regulated in the same way that publicly funded hospitals are, so there is no guarantee the quality of the treatment or whether it will work.  In fact, it they state the treatment will absolutely work, that is a sign you should look elsewhere, as this is an extreme claim.  Brain injury is so individualized and complex, there is no “one size fits all” treatment for everyone and no guarantee that a treatment will work for you.

Private clinics are not always covered by insurance and you may have to pay out of pocket. This is something to keep in mind

When looking at private clinics, make sure you ask a few important questions:

  • Is the treatment evidence-based and could they share the research with you?
  • What is the benefit of the treatment related to the cost?
  • What is the wait time for treatment?

Disclaimer: There is no shortage of web-based online medical diagnostic tools, self-help or support groups, or sites that make unsubstantiated claims around diagnosis, treatment and recovery. Please note these sources may not be evidence-based, regulated or moderated properly and it is encouraged individuals seek advice and recommendations regarding diagnosis, treatment and symptom management from a regulated healthcare professional such as a physician or nurse practitioner. Individuals should be cautioned about sites that make any of the following statements or claims that:

  • The product or service promises a quick fix
  • Sound too good to be true
  • Are dramatic or sweeping and are not supported by reputable medical and scientific organizations.
  • Use of terminology such as “research is currently underway” or “preliminary research results” which indicate there is no current research.
  • The results or recommendations of product or treatment are based on a single or small number of case studies and has not been peer-reviewed by external experts
  • Use of testimonials from celebrities or previous clients/patients that are anecdotal and not evidence-based 

Always proceed with caution and with the advice of your medical team. 

Support groups

Seek the support from other people who have been in a similar position as you and have found success with other therapies, treatments or recovery methods.  Brain injury associations across Canada offer groups online and in-person for individuals living brain injury. Some are geared towards targeted groups such as women, men, youth. Find your closest brain injury association to see what they have to offer.

Nutrition

We are what we eat, which means that our diet has a big impact on our brain’s health and well-being. Visit the section on nutrition to see how to optimize your diet for brain health.

Sleep

No matter what stage you are at in your recovery, you need as much restful sleep as possible.  Both cognitive and physical fatigue can affect so many aspects of daily living, including mood, memory, concentration, communication, and your general ability to deal with issues or situations.

Take a step back

Take a step back and slow down. Sometimes we need to pause and listen to our bodies. Look at what may be triggering your symptoms. You may be juggling too many things at once.  It could be something in your environment, such as the lighting in your home or office. It is important to remember that recovery can take time, so you need to be patient and look at the whole picture.

Do something you enjoy

When you are not feeling well, it is hard to focus on the positives. Do something you enjoy or that brings you happiness and relaxation. Try to build this into every day. Doing activities that make you feel fulfilled can help you in your recovery process.

Become educated on your health

Individuals as much as possible need to become their own health advocates.  Becoming as educated as possible on the topics and treatments for brain injury will help you better communicate with your health team and bring new information that might be helpful in recovery.

Here are some helpful tips to help you advocate for your health:

  • Write down some talking point or notes so you don’t forget anything and can speak clearly with the healthcare provider
  • If you have articles or research papers about brain injury you want to share with your clinician, bring copies to your appointment. Try to limit the resources you bring to three or less
  • Ensure your sources of information are reputable, credible and based on evidence.
  • University and medical research centres are examples of reputable sources
  • Be open to their perspective and knowledge of the topic. Take notes (or have someone take notes for you)
  • Ask for more links or resources so you can be more informed

Use your voice

You have a powerful voice as a person with lived experience. You can use this power to advocate in your community. Reach out to your local brain injury association to see how you can share your experience and challenges and contribute to advocacy efforts.

Stroke

Stroke is a brain injury caused when blood flow is to the brain is suddenly interrupted due to a clot or a ruptured blood vessel. The interrupted blood flow causes damage to the brain. Stroke can happen at any age and may result in the loss of the ability to move, to communicate, to process information, to swallow, to cope with stress, and more. Its after-effects often include extreme fatigue, depression, anxiety, deficits with memory, attention and vision, and the inability to sense self-movement and body position. Deficits depend on where and how much damage has occurred in the brain.

That is why, at the first signs of stroke (listed below), it is essential to call 9-1-1 and seek immediate medical attention to limit or, in some cases, reverse damage.

Topics in this section include:


Types of stroke leading to brain injury

About 85 per cent of strokes are ischemic, caused by a clot that blocks blood flow to the brain, and the remainder are hemorrhagic, caused when a weakened blood vessel bursts. A brain scan at the hospital will quickly determine the type and location of the stroke and the emergency treatment required.

Both kinds of stroke have similar symptoms, including drooping face, slurred speech, weakness, numbness, dizziness, confusion, and sudden severe headache. (See FAST, below)

Acute treatments are different, depending on the type and location of the stroke, which is why calling 9-1-1 and seeking immediate medical attention is critical. For both types of strokes, the patient will have a rehabilitation and treatment plan to follow when they leave the hospital.

People can also have a fleeting stroke called a Transient Ischemic Attack, or TIA. It is sometimes called a mini-stroke. TIA symptoms may only last for a few minutes, and usually less than a hour, and normally result in no lasting injury to the brain. However, a TIA is a warning sign that a more serious stroke may occur soon and medical care is required right away by calling 9-1-1.

Identifying a stroke using FAST

The key to minimizing the damage a stroke can do to the brain is getting medical attention as quickly as possible. The Heart and Stroke Foundation advocates using the FAST method to identify strokes in others (or in some cases, yourself). FAST stands for Face, Arms, Speech, and Time.

  • Face – is it drooping?
  • Arms – can both be raised?
  • Speech – is it slurred
  • Time – call 9-1-1 immediately

These are the main symptoms of stroke. Additional symptoms can include confusion, loss of consciousness, sudden and severe headaches, and nausea/vomiting.

Effects of stroke

A stroke causes damage to the brain, which can result in a variety of physical, emotional and cognitive effects that change the ability to move, communicate and process information. These effects can include:

  • Attention and memory deficits
  • Balance challenges
  • Bowel and bladder problems
  • Emotional challenges, like depression
  • Low energy
  • Muscle weakness
  • Paralysis – this can be localized (face, arm, or leg)
    • Hemiplegia (paralysis on one side of the body)
    • Quadriplegia (paralysis of all four limbs and trunk)
  • Sensation changes
  • Speech problems
  • Swallowing problems (dysphagia) 
  • Vision problems

These changes can make it difficult to prepare food, drive, work, or complete leisure activities.

Stroke and brain injury rehabilitation

In the first few days, doctors will be trying to stabilize you and make a medical diagnosis. Then recovery begins. The first stages of recovery can take different lengths of time for different people. You may feel tired and experience weakness. The medical team will work with you until you’re able to move to rehabilitation and be discharged from the acute care or stroke ward of the hospital.

Rehabilitation will vary depending on your needs, but the goals remain the same: to recover or adapt your abilities as best as possible. It will include physical, mental and cognitive exercises. It may also include working with a speech language pathologist (SLP) on speaking and swallowing. Occupational therapists (OT) can help with activities of daily living (ADLs), motor skills and home environments, and physical therapists (PT) can assist with muscle strengthening and range of motion (ROM) exercises. Rehabilitation takes a lot of time, practice and patience but it will help you regain independence by relearning or adapting your abilities.

Risk factors for a stroke

There are several lifestyle and conditional factors that can increase a person’s risk of stroke.

Lifestyle changes can improve your overall health while reducing risk of stroke. Conditional factors such as blood pressure and diabetes can be addressed with doctors, medications, and in some cases lifestyle adjustments.

Resources & Research


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Cognitive effects

Individuals with acquired brain injuries experience cognitive impairments that can impact them for the rest of their lives.

Topics in this section include:


Changes in cognitive abilities

Attention & concentration
Attention is being able to focus on something. There are several different types of attention, including:

  • Selective (focused) attention: This is being able to ignore distractions. Examples of challenges with selective focused attention may include being unable to focus when there are multiple people talking or being easily distracted while driving. Other examples include forgetting what you were going to get from the bedroom, or trouble preparing a meal.
  • Sustained attention: This is how long you can concentrate on an activity or task. Sustained attention depends on factors such as the task, how tired you are, and environmental distractions.
  • Spatial attention: This is your ability to be aware of specific locations in the environment.
  • Alternating (divided) attention: This lets you switch from one task to another without losing track of what you’re doing, and to keep track of several things at once. This may be difficult to do after a brain injury.
  • Attentional capacity (‘working memory’): This is how much information you can take in at once without getting overloaded and your ability to use that information. For example, the average adult can hear and repeat a 7-digit phone number but usually won’t remember it 5 minutes later. After a brain injury, you may not be able to take in as much information.
  • Prospective memory: This is the ability to plan, retain and retrieve an idea as planned. For example, if you need to run an errand, you need to plan to stop at the store, remember to stop at the store, and complete your errand. This memory can be challenging for someone with an acquired brain injury because planning can be difficult.

The changes in attention that can happen after a brain injury can make it hard to follow a conversation, hard to work, or make it unsafe to cook a meal or drive. In the early stages of recovery, you might not be alert enough to communicate or be fully aware of your environment. If you can focus on something, it may only be for a short amount of time.

At times, one small detail or focus on the wrong information may cause you to be distracted. These distractions could be internal: for example, you might be distracted because you need to go to the bathroom. The distraction could be external: for example, while talking, your attention may be on someone’s tone of voice or clothing rather than what they are saying. You could be trying to pay attention to words, how you look, noise from the street, and other activity in the room all at the same time.

If you can’t concentrate, it’s hard to finish a task. You might know what you need to do, but have trouble keeping track. We all have problems concentrating, especially when we’re tired or don’t feel well. For individuals with a brain injury, it can be so difficult to pay attention or concentrate that it’s hard to do even the simplest task like washing your hands or dressing.

Tips to help with concentration and attention

  • Ask people to repeat the things they say to you and break it up into small bits of conversation. This will help you absorb the information.
  • Break tasks into small steps.
  • Engage in hobbies or activities that you enjoy and can do. Card games, puzzles, and reading help develop concentration and are entertaining at the same time.
  • People who have trouble focusing may get tired quickly. Make sure you take short breaks to give your brain a rest.
  • Reduce distractions; have only one person in the room, turn off the TV or radio, and try to limit the number of things you’re doing at the same time.
  • Take away time pressures. Don’t rush through a task or expect it to be done perfectly.
Judgement and problem-solving
Problem-solving and judgment may be impaired after a brain injury. You might have trouble judging a situation, figuring out what the right response should be, or act on your first impulse. Your thinking style may not be flexible – in other words, once you make up your mind, it can be hard to change it.

Problem-solving skills are incredibly important for living independently and safely. You may need to work with specialists or caregivers to develop these skills.

Tips for judgment and problem-solving

  • Ask for feedback on your behaviour. You can ask your psychologist, occupational, or speech therapist for ideas on how to do this
  • Consider the possible reactions of people that would be affected by your decision
  • Make a list of choices – or ask your caregiver to give you choices – when it comes time to decide. For example, have your caregiver ask if you want to go for a walk, practice exercises or watch TV instead of asking what you want to do
  • Reduce distractions that could affect your decision-making process
  • Take extra time to clearly think about your decision
  • Try planning and reasoning out loud so you can more clearly think about your decisions. You can also have a caregiver listen to you and make suggestions
  • Work with a caregiver, friend, or family member on decisions whenever possible
  • Write down the important things to think about when making a decision. This gives you a guide to refer to during the process
  • Write down problems or situations from the past – they can help with decision-making in the future.
Language & communication
After a brain injury, it’s common to have trouble with speaking, understanding language, writing and reading. This includes:

  • Difficulty expressing yourself
  • Difficulty finding words
  • Difficulty understanding others
  • Trouble with conversation
  • Trouble with facial expressions or tone
  • Difficulty organizing your speech
  • Not being able to respond appropriately

These challenges can come from physical issues with control over your tongue, mouth and throat muscles. They can also arise from damage to the parts of the brain that control and understand language (this is called aphasia).

Tips to improve communication skills

A speech-language pathologist can help identify the best strategies for successful communication when a person has a brain injury, but there are a few general guidelines that can help you communicate:

  • Find a place where you feel comfortable talking and listening, where you don’t feel pressured or distracted
  • Don’t turn on a TV, radio, or other noisy items when you want to communicate with someone
  • Talk and listen to one person at a time. Group conversations can be overwhelming and hard to follow
  • If you don’t understand someone, ask them to repeat themselves or use different wording
  • Take your time to think and speak – there’s no rush

It is also important to show patience and understanding. This is an adjustment for everyone and tempers and frustration can run high. It’s normal to experience those feelings, but it’s important to make sure you are doing what you can to address those feelings appropriately.

Memory
Memory is generally divided into two categories: declarative and non-declarative. Declarative memory is things that can be clearly remembered such as specific past events (episodic memory) or knowledge and facts (semantic memory). Non-declarative procedural memory is memory that is retained as a skill or a motor response.

How memory is affected depends on the brain injury. Some individuals lose their memories of time before or immediately after the injury. Others are unable to make new memories, while still others forget skills or motor responses that used to be second-nature, although this is less common.

The most common types of memory loss after a brain injury are:

  • Short-term memory loss: This means you can’t remember things that just happened and are often influenced by problems with attention.
  • Amnesia: This most commonly refers to loss of declarative (episodic) memory after damage to specific areas of your brain’s memory system. Amnesia can be divided into anterograde and retrograde.
    • Anterograde amnesia: This means the inability to form new memories, after the time of injury, and is often the result of short-term memory loss.
    • Retrograde amnesia: This means you’ve forgotten what happened before your brain injury.

On rare occasions, a person with memory loss may remember things that did not happen or twist events. This is called confabulation, and it’s done automatically without the person realizing it: they don’t know that they are making up information and tend to not fully recognize the impact of their brain injury.

Problems with memory can affect progress in all areas. If memories fade quickly, you won’t be able to learn from new experiences, remember that you’re making changes or remember that you’re improving. This can have a huge impact on rehabilitation. In therapy, you’re learning mobility skills, how to use assistive devices, how to communicate and how to process information. If you have trouble remembering what you learned from one day to the next, progress may be slower.

During the assessment stage of therapy, therapists will test memory for events that happened:

  • Before the accident (remote or retrograde memory)
  • In the past few minutes (immediate memory)
  • In the past few minutes, hours, or days (recent or anterograde memory)

Immediate and recent memory tends to be more affected by a brain injury than remote memory.

Memory recovery is often slow, and in some cases a person may never fully recover. This can be incredibly frustrating and upsetting for both you and family/friends. It’s important to be gentle with yourself, and as you cope with the changes surrounding your brain injury that you do what you can to take care of your mental and emotional health.

There are steps you can take to help with any memory changes you may be experiencing.

Tips to help with memory

  • Be patient with yourself. It’s frustrating to not be able to remember things, but you’re working hard. Take the time you need, ask people to repeat themselves if needed, and be kind to yourself when you’re working on your memory
  • Choose activities that are familiar to you – this will help you form memories, and create enjoyable experiences
  • Having routines helps all of us remember, so consider creating routines for events that are repeated everyday, like when you have meals or where you put the housekeys
  • Try to use one calendar system for keeping track of events, rather than several different systems in different rooms or situations
  • Use any calendar or routine consistently – consistency helps make habits and avoids confusion
  • It’s a good general rule to write things down if you need to remember them. Have paper and a pen or pencil with you so that you can write down important points, or ask the person with whom you’re speaking to write down what they want you to remember
  • You can buy devices that shut off stoves and other appliances automatically. This can help to prevent safety hazards
Planning skills
Many people with a brain injury find it hard to plan, begin, and finish an activity. You may not be able to think ahead or lack follow-through to finish a task. Your thinking may be disorganized and incomplete. This may show up as repetitive movements or comments. You might act impulsively by doing something quickly without thinking or need a lot of time to understand information and respond the right way.

Planning is an important part of building independence. For example, you need to be able to do laundry, so you have clean clothes. This means you need to know when to add soap, how to set your washing cycle, and how to set your drying cycle. You may not be able to plan out all the steps right away, but by setting goals and working with rehabilitation specialists, you can develop your planning skills.

Tips to help with planning

  • Break down the task into small steps. For example, when making a salad, first prepare the lettuce. When this is done, proceed to the next step, and so on
  • Have a caregiver, friend, or family member clearly and briefly explain the activity before you start
  • Read instructions or have directions read to you slowly so you have time to understand and respond
  • Reduce distractions, reduce the demands, and give yourself extra time to problem-solve
  • Routines and schedules outlining future events help with better organization
  • Use a checklist so that you can check off each step of a task as you do it
  • Use a calendar or whiteboard to provide visual cues and reminders
  • When possible, help with household chores (as much as you can do). Things like setting the table, washing the dishes, or preparing a salad need planning but may be familiar enough that you can do them easily. These kinds of activities will help you practice step-by-step planning
  • Daily activities tracker
Self-awareness
It’s common after a brain injury for a person not to be as self-aware as they were before. For example, an injured person may not be aware of what they can’t do anymore. They may not notice or remember the changes in themselves, be in denial, or grieving those changes, which are emotional responses. Or they feel pressure to return home or return to work even if they are not completely ready. This may lead to the person overestimating their abilities and underestimating their problems.

Self-awareness is difficult to spot in yourself. This is when you need the help of therapists, caregivers, family, and friends. Your support team will help you figure out the best ways to receive feedback and identify ways to improve self-awareness. For example, perhaps you’re more likely to listen to a sibling vs. a parent, or a doctor over a family member when receiving feedback.

It’s important to note that these symptoms of cognitive changes after a brain injury won’t happen in everyone. They can also happen for people with mental health disorders, the aging population, and people with different illnesses. People who experience cognitive symptoms following an acquired brain injury (ABI) should be referred to a neuropsychologist for formal neuropsychological testing that can provide insight into the root cause of the symptoms. These results and the profile of your cognitive needs will be used to create individualized treatment plans.

Cognitive rehabilitation and recovery

Every person is unique, and so is each brain injury. For that reason, it is impossible to predict how recovery will impact your cognition (thinking skills). Cognitive rehabilitation is a tool that can have a positive impact. Cognitive rehabilitation is a collection of treatments that work to improve a person’s cognitive functioning in everyday life after injury. A variety of different professionals are involved in cognitive rehabilitation, but the most common therapists are licensed Speech-Language Pathologists (SLPs) or Occupational Therapists (OTs). Sometimes therapy is delivered by a person called a “cognitive rehabilitation therapist” (CRT).

For cognitive rehabilitation to be effective, it must be designed specifically for your needs and your goals, with a focus on both your cognitive strengths and areas you find challenging.  Each person is different, which means rehabilitation plans needs to be as well.

Cognitive rehabilitation can be helpful even years after injury. It’s never too late to seek support to develop cognitive skills and address challenges you may be facing.


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