Archive for category Cognitive Rehabilitation

[ARTICLE] An acceptance and commitment therapy-based intervention for PTSD following traumatic brain injury: a case study

Introduction: A case study is presented to illustrate the management of Post-Traumatic Stress Disorder (PTSD) in the context of Traumatic Brain Injury (TBI), using an Acceptance and Commitment Therapy (ACT) based approach. A 48-year-old female presented to Neuropsychology with cognitive difficulties, significant distress and trauma symptoms following a car accident. ACT is a third wave cognitive-behavioral approach aimed at increasing psychological flexibility as a means of reducing distress: it is a trans-diagnostic model that may be suited to the complex and multi-factorial difficulties experienced by this client group.

Methods: A guided self-help approach based on ACT was implemented by the client working with a Clinical Psychologist within a Community Neuropsychology service, over 12 appointments.

Results: Outcome measures were administered pre and post-intervention as well as at three and then 12-month follow-ups. Improvements were seen across ACT outcome measures, psychological measures and quality of life ratings and were consistent with subjective reporting.

Discussion: Outcomes were positive in all domains post-intervention and at follow-up, indicating that this may be a feasible intervention for PTSD following TBI.

via An acceptance and commitment therapy-based intervention for PTSD following traumatic brain injury: a case study: Brain Injury: Vol 0, No 0

, , , , , ,

Leave a comment

[ARTICLE] Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury – Full Text

Objective: Prolonged mental fatigue and cognitive impairments are common after a mild traumatic brain injury (TBI). This sets limits for rehabilitation and for regaining the capacity for work and participation in social life.

Method: This follow-up study, over a period of approximately 5.5 years was designed to evaluate the effect and safety of methylphenidate treatment for mental fatigue after a mild TBI. A comparison was made between those who had continued, and those who had discontinued the treatment. The effect was also evaluated after a four-week treatment break.

Results: Significant improvement in mental fatigue, depression, and anxiety for the group treated with methylphenidate (p < .001) was found, while no significant change was found for the group without methylphenidate. The methylphenidate treatment group also improved their processing speed (p = .008). Withdrawal produced a pronounced and significant deterioration in mental fatigue, depression, and anxiety and a slower processing speed. This indicates that the methylphenidate effect is reversible if discontinued and that continued methylphenidate treatment can be a prerequisite for long-term improvement. The effect was found to be stable and safe over the years.

Conclusion: We suggest methylphenidate to be a possible treatment option for patients with post-TBI symptoms including mental fatigue and cognitive symptoms.


Long-term mental fatigue and cognitive impairment are common after a mild, moderate or severe traumatic brain injury (TBI) and these can have a significant impact on work, well-being and quality of life (1). Fatigue and concentration deficits are acknowledged as being one of the most distressing and long-lasting symptoms following mild TBI (1). There is currently no approved treatment (2), although the most widely used research drug for cognitive impairments after TBI is methylphenidate (3). A few studies have used methylphenidate for mental fatigue after TBI with promising results including our own (4,5). Other clinical trials of drugs have reported improvements in mental fatigue ((−)-osu6162 (6)) or none ((−)-osu616, modafinil (79)).

In our feasibility study of methylphenidate (not placebo controlled) we reported decreased mental fatigue, improved processing speed and enhanced well-being with a “normal” dose of methylphenidate compared to no methylphenidate for people suffering from post-traumatic brain injury symptoms (4). We tested methylphenidate in two different dosages and found that the higher dose (20 mg three times/day) had the better effect compared to the lower dose. We also found methylphenidate to be well tolerated by 80% of the participants. Adverse events were reported as mild and the most commonly reported side-effects included restlessness, anxiety, headache, and increased heart rate; no dependence or misuse were detected (10). However, a careful monitoring for adverse effects is needed, as many patients with TBI are sensitive to psychotropic medications (11).

Participants who experienced a positive effect with methylphenidate were allowed to continue the treatment. We have reported the long-term positive effects on mental fatigue and processing speed after 6 months (12) and 2 years (13). No serious adverse events were reported (13)(Figure 1). In a 30-week double-blind-randomized placebo-controlled trial, Zhang et al. reported that methylphenidate decreased mental fatigue and improved cognitive function in the participants who had suffered a TBI. Moreover, social and rehabilitation capacity and well-being were improved (5). Other studies evaluating methylphenidate treatment after TBI have focused only on cognitive function reporting improved cognitive function with faster information processing speed and enhanced working memory and attention span (1421). A single dose of methylphenidate improved cognitive function and brain functionality compared to placebo in participants suffering from post-TBI symptoms (22,23). Most of these have been short-term studies covering a period between 1 day and 6 weeks and included participants suffering from mild or more severe brain injuries.

This clinical follow-up study was designed to evaluate the long-term effect and safety of methylphenidate treatment. We also evaluated the effect after a four-week treatment break and compared the subjective and objective effects with and without methylphenidate. Patients who had discontinued methylphenidate during this long-term study were also included in this follow-up, as it was our intention to compare the long-term effects on mental fatigue in patients with and without methylphenidate treatment.



Continue —->  Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury: Brain Injury: Vol 0, No 0

, , , , ,

Leave a comment

[WEB SITE] Hack Your Vagus Nerve to Feel Better: 14 Easy Ways

By Victoria Albina

For folks with symptoms ranging from fatigue to depression and anxiety, digestive issues from IBS to SIBO to IBD, to brain fog and even food sensitivities, the Vagus Nerve almost always plays an important role in both sickness and healing, and needs to be supported so you can truly and deeply heal.

Hack your Vagus Nerve

What is the vagus nerve?

• Vagus means “wanderer” in Latin, and the vagus nerve wanders from the brain through most of the body.
• The vagus is the longest of the cranial nerves. It starts in the brain, where it sends signals to the cells there. It then wanders through the body, from the brain through the neck and throat to the heart and lungs. The vagus moves down to the gut and digestive organs – liver, pancreas, gallbladder – and all the way through to the kidneys and to the uterus.
• Signals are constantly flowing from the brain to the body and back from the body to the brain, via the vagus nerve.
• Vagus nerve “tone” is key, and activates the parasympathetic nervous system. The“rest and digest” system, and improved vagal tone supports your body and mind in relaxing faster after stress.
• Studies have shown that there is a positive feedback loop between vagus tone, optimal physical health and positive emotions. That is, the more you support your vagus nerve and improve tone, the better you’ll feel overall.

Think about a Technical Knockout (TKO) punch in boxing – it’s a straight shot to the vagus nerve. Because this nerve goes through most of the body and enervates, or gives nerve activity to, so much of the body, a strike to it knocks you out cold. The body is very protective of the vagus nerve. Any alteration in the normal, pre-programmed flow can lead to big changes downstream in the body.

Some folks with constipation or those with hard or large stools can experience body-wide symptoms resulting from pressure on the vagus nerve – cold sweats, anxiety, tingling in hands and feet, and more – all from a really hard stool! I had a patient once who would frequently literally pass out from a large, hard bowel movement. Which goes to show how much having the correct vagus signaling effects our bodies. (she’s better now, by the way.  She had really intense methane SIBO, which we tested for, found and treated. No more unconsciousness on the bathroom floor, thank goodness)

Some common symptoms of Vagus Nerve Dysregulation:

• Irritable Bowel Syndrome (IBS)
• Small Intestine Bacterial Overgrowth (SIBO)
• Depression
• Anxiety
• Chronic Fatigue
• High or Low Heart Rate
• Difficulty Swallowing
• Insomnia or trouble sleeping
• Gasteroparesis, also known as delayed gastric emptying
• Heartburn, reflux, gastritis or GERD
• Dizziness/Fainting
• B12 Deficiency
• Chronic Inflammation
• Weight regulation issues (1)

Fight or Flight: Lion-Based Consciousness

There are two important nervous systems in our bodies: the sympathetic, or “fight or flight” and the parasympathetic or “rest and digest.”

The vagus nerve is part of the parasympathetic system. This is the system that supports us in chilling out, centering, calming ourselves, as well as digesting our food, having a healthy reproductive system, and healing.

Back in the day, humans had to keep a constant and vigilant eye out for lions. We had to hide from, run from, possibly fight, lose to and get eaten by, lions. Our bodies are pros at Lion-Based Consciousness. And when we’re on high alert for predators, our bodies are in “fight or flight” or sympathetic dominance. In that state, the vagus nerve is neither giving nor getting the signals it needs to do its job properly, and to support us as we attempt to rest and digest.

Studies show that there aren’t a lot of lions hunting the average American these days.  The percentage of Americans, both urban and rural, reporting actually encountering a lion during the course of their day has dropped precipitously since the recent closing of Barnum & Bailey Circus. Meanwhile, our bodies haven’t caught up to the fact that the little stressors of daily life aren’t likely to lead to us being killed and eaten, and these big and little stressors keep your vagus nerve from signaling optimally. Modern life for the average human is full of imaginary lions, stressors that keep our bodies out of optimal balance, and full of inflammatory chemicals.

Let’s Talk Digestion and the Vagus Nerve

When vagus function is out of whack, digestion is out of whack. Symptoms can include heartburn or GERD, IBD or inflammatory bowel disease like ulcerative colitis, and can prevent the body from healing Small Intestine Bacterial Overgrowth (SIBO), a frequent root cause of Irritable Bowel Syndrome (IBS).

The vagus nerve is part of the system that tells the stomach to put out digestive acids and juices, and to start the movement of the gut. When we chew our food, we start the process of mixing the fibers in our food with the digestive acids and enzymes that begin to break food down, before it reaches the stomach, before flowing into the small and then large intestines.

When the vagus nerve isn’t getting or sending the right signals, the flow of food-mixed-with-acid through the gut is slowed. This means that overgrowths of bacteria, yeast or parasites — as well as used up hormones and toxins that the body worked to eliminate from the body — are moving through the gut at a slower rate. IBS and SIBO risk are increased with more exposure to bacteria, waste products,potentially  worsening any infections present. Exposure to more hormones than your body had planned on can throw hormones out of balance (discussed further below).

Vagus Nerve, MMC and SIBO

In the case of Small Intestine Bacterial Overgrowth (SIBO) the migrating motor complex (MMC) in the gut is not behaving optimally.

I like to think of the MMC as the caboose of a little train moving through our intestines. You eat, and the chewed up food, combined with digestive acids and enzymes, is loaded onto a car on the train, to be moved through your body and out as stool. Every time you eat, the train has to stop and go back to the top of the tracks to pick up the new food.

Several things can stop the train. Reduced vagus nerve firing is a major contributor to MMC dysregulation. Snacking is another one for sure. The train should move all the way through from Central Station, the place right after your stomach (the duodenum) through to its final stop downtown, the anus.

This should be a one-way trip, and the train should leave the station and get to the end of the road every 90-120 minutes. Every time you snack, the train has to stop and go back to pick up this new food-passenger, slowing the movement of food through your digestive track, which can lead to bacterial overgrowth and increased toxin burden in the body.

The MMC can also get derailed or confused by trauma, stress, and other life factors, to be discussed in depth in further articles.

Low Stomach Acid

Folks with IBS, heartburn, reflux and other digestive issues often have low stomach acid, and this too can be a vagus nerve issue. The vagus nerve prompts the cells in the stomach to release histamine, which helps the body to release the stomach acid you need to break down your food.

Low B12 Levels Can Make You Feel Terrible

Many people with chronic digestive concerns also have low B12 levels, which is often due, in part, to not having enough vagus stimulation of the parietal cells in the gut, which leads to low intrinsic factor. Intrinsic factor is the chemical that processes B12 in the stomach, and the cells that release it can be hurt or even killed by eating foods we’re sensitive or allergic to or by having untreated heartburn, gut infections or inflammation.

The function of these cells can be slowed by inappropriate vagus nerve stimulation – if the gut isn’t getting the “All Systems Go” signal from the brain, why would your stomach use all that energy to make B12?

Low B12 levels are linked to fatigue, depression, anxiety, memory problems and dementia, nerve problems such as numbness or tingling, weakness in muscles, GI symptoms such as constipation, gas, diarrhea or lack of appetite.

Let’s Talk Hormones and Lions

I want to go back to talking about Lions here – both real and imagined.

When the vagus nerve is over or under-active, the brain’s hypothalamus isn’t signaling the brain’s pituitary gland appropriately, and the downstream signal to the adrenal glands gets confused. This system is known as the HPA Axis, and when this communication is effected, several hormones can get over- or under-produced (CRH, ACTH and cortisol). This can be part of the set of symptoms commonly referred to as “Adrenal Fatigue.” While that name is not exactly scientifically correct, it’s a useful shorthand for chronic exhaustion or hyper-stimulation leading to anxiety, insomnia and just generally feeling revved up.

That is to say:  your body can get triggered into thinking either that All The Lions Are Chasing You Always, or that there is not a single lion out there in the world, nothing to run from, nothing to do, why bother being awake and present to the lion-free world… This can lead to a combination of fatigue, lack of motivation, anxiety, insomnia and generally, a case of the blahs. Vagus nerve stimulation plays a role in helping the body understand when a situation is a True Lion, and when it’s just your boss being your boss, or a looming deadline that feels like doom.

Let’s Talk Circadian Rhythm

A very modern problem that I see daily in my patients is an alteration in circadian rhythm, or our body’s natural sleep/wake signaling. Part of this problem is that most of us have limited activity during the day – we take the subway or car to work, sit for 8-10 hours, car or subway home. We don’t see the sun during our work day, and then sit in front of blue lights at night, such as our phones, television, tablets and computers, which actually tell our brains that its daytime. The blue light that is part of every screen we use mimics the sun, which tells our bodies that it’s time to be awake (and that the lions are awake too), and that our pineal glands in our brains shouldn’t put out melatonin.

I know how tempting it is to check social media before bed, and I know I’m not gaining any fans by urging you to read a paper book before bed… but there are few things your body wants more.

The vagus nerve transmits signals from the circadian control center in the brain, and the effect of circadian dysregulation goes in both directions. Interrupting circadian flow affects the brain, and changes in normal melatonin and other hormone levels before bed can lead to problems with the vagus nerve, which then affects the rest of your body. Furthermore, the circadian control center in the brain sends signals to your digestive system and lungs to produce mucin, the substance that keeps your vital organs healthy and well-lubricated, but only if it’s getting the right signals to do so.

How can regaining appropriate Vagus Nerve Stimulation help you?

It’s simple: when you get your vagus nerve back in proper working order, all the systems listed are free to work optimally. The overall function of your heart, lungs, digestion, reproductive and hormone systems can all be improved by optimizing vagus nerve function.

How to start reengaging the vagus nerve:  it’s simple, easy and fun!

Pick one or two things to start adding to your daily routine – start simple, and see if stimulating the vagus nerve can become part of your health care habits!

1. Sing. Loudly! Not a quiet hum, but a full on, top of your lungs good ole sing along. I recommend the shower for this one.

  • The muscles in the back of your throat activate the vagus nerve as they move, so sing as loud as possible. Don’t worry about the neighbors. (2)
  • Oxytocin, the calming hormone released at birth is also released when we sing. (3)

2. Gargle. You can use regular filtered water for this. I’m a lover of efficiency, so I do this in the shower too. I have a water filter on my shower (I like Berkey brand so I can trust that the water I’m gargling is clean and the chlorine has been removed (which my hair and skin and lungs thank me for, too). Once that conditioner is in my hair and doing it’s magic, I gargle like a full-on Muppet. Not a discreet, elegant gargle – the gargle of a small-and-friendly monster.

  • You want to gargle hard enough that your eyes start to water
  • The added benefit of this is that it makes me laugh, and laughter is amazing medicine! (4, 5, 6) In this case, laughter stimulates the vagus nerve too. Laughter increases beta-endorphins and nitric oxide and benefits the vascular system. (7, 8)
  • It’s a win win win. And my hair looks Amazing.

3. Build in some daily prayer and meditation, especially chanting. Try an ommm or two. It may feel silly or weird at first, but it’s good for your health and wellness, as what vibrates the throat stimulates the vagus nerve. It frankly doesn’t matter what you chant, just get to it.

  • I love to think about all the things that humans have done since time immemorial because they were just the things that we did. Most religions have some sort of chanting, singing, meditation – from the Rosary to Buddhist chanting to Pagan spiral song to the rhythmic prayer of Judaism. Atheist or just not down with religion? That’s cool. Try chanting whatever noise feels good for you.
  • I try to channel my toddler nephews – they’ll take any opportunity to make ridiculous noises and to chant what sounds like nonsense any chance they can – they have an inherent kiddo wisdom that helps their little bodies as they grow and learn. Close the bathroom door, gargle, sing the praises of the Universe or just make loud silly noises. It’s surprisingly freeing…

4. Expose yourself to cold water or air. The vagus nerve is stimulated when the body is exposed to cold. The sympathetic fight/flight system is downregulated (works less) and the parasympathetic rest/digest system is upregulated, or asked to work more to calm you.

  • I splash my face with cold water every morning, and at the end of a shower I turn the water as cold as it will go for as long as I can stand it. I started with 2 seconds, and am working up to 2 minutes. (9) Or you can start slowly by putting your face in ice cold water for a few seconds.
  • In the winter, I like to open a window in the morning to both greet the day and to get a blast of cold air for just a few seconds.

5. Do yoga. Both the parasympathetic nervous system and the vagus nerve are stimulated by yoga practice, particularly the Sun Salutation. (10,11)

  • A study that compared a group of people who walked daily to those doing yoga daily found a significant reduction in anxiety and perceived stress in the yoga group, as well as increases in the mood-improving, anti-anxiety brain chemical GABA. (12)

6. Meditate. Meditation and deep breathing stimulate the vagus nerve. (13, 14, 15)

  • Whatever meditation works best for you is the best kind to do – some folks like a guided meditation, some like to focus on the breath, taking 5-10 deep, slow belly breaths. It doesn’t matter what you choose, as long as you make a daily habit of doing at least 2 minutes of meditation every day.

7. Breathe Deeply and Slowly. There are neurons in both the heart and the neck that contain baroreceptors, or cells that monitor your blood pressure, and send signals back and forth with your brain.

  • When we take deep, slow belly breaths, we activate the vagus nerve to lower fight or flight, and activate our rest and digest parasympathetic nervous system, thus lowering heartrate, blood pressure and feeling of anxiety. (16)
  • On average, we take 10 to 14 breaths per minute – but to stimulate the vagus nerve, try to take only 6 breaths per minute. Breathe in deeply, allowing your stomach to expand, then breathe out very slowly. (17)

8. Serotonin and 5HTP. The neurotransmitter chemical Serotonin activates the vagus nerve through a variety of different receptors in the brain, gut and throughout the body. When there is inflammation in the gut, the amount of serotonin made in the brain is reduced via the quinolate pathway.

  • The best way to support optimal brain-body chemistry is start by understanding what is going on in your gut. We can use advanced functional medicine stool and breath tests to evaluate the gut microbiome to see what may be causing inflammation for you. This is something I do for all my patients, especially those with digestive issues, depression, anxiety, skin concerns, hormone imbalances or sleep issues.
  • Taking the serotonin precursor 5HTP can help with systemic serotonin support. This supplement can interact with some medications, so be sure to talk with your licensed healthcare provider before starting 5HTP!

9. Add in Prebiotic and Probiotic foods and supplements. The term “gut microbiome” refers to the millions of bacteria in our digestive track, which play a role in nutrient absorption, mood, hormone and neurotransmitter balance to name a few vital functions. The health of our microbiome is a huge determinant of our overall health.

  • The vagus nerve is the great connector between the brain and the enteric nervous system, which controls digestion and the gut. Our microbiome plays an important role in making this signaling work.
  • Specifically, the probiotic bacterial strain Lactobacillus rhamnosus was shown in animal studies to support optimal levels of the receptors of the calming chemical GABA, which is mediated by the vagus nerve. (18)
  • For more on fermented foods, check out these recipes (sauerkraut, beet kvass) for affordable probiotics you can make at home.
  • Prebiotics, food for the colon cells, are found in fibrous vegetables. Aim for 6 or more servings of a variety of vegetables each day to optimize the health of your gut, microbiome, colon and vagus nerve.

10. Exercise. When we move, the digestive system is stimulated, and the parastaltic wave which moves stool through the colon is also activated.

  • This movement is controlled in part by the vagus nerve, which is also stimulated by exercise, from walking to yoga to crossfit.
  • Whatever exercise or movement works for you is the right thing to start with. Try to get some gentle movement daily! (19)

11. Acupuncture. Humans have been stimulating the vagus nerve with acupuncture for ages, and there are several commonly used points which stimulate improved vagus function. (20) Studies show that auricular or ear acupuncture is particularly stimulating for the vagus nerve. (21) (22)

12. Eat fish! Studies show that comsuming omega 3 fatty acids (like those found in fatty fish like salmon) increases vagal tone and activity and puts us into that calming parasympathetic mode more often. (23) I recommend eating small fish, as they have fewer heavy metals in them.

13. Get a massage. Massaging different parts of the body, especially the feet or along the carotid sinus (on the ride side of your neck), which you can do on your own for free, can also stimulate the vagus nerve. Massage is often used to get newborn babies to gain weight because it stimulates their vagus nerves, thereby increasing their gut function. (24)

14. Try Intermittent Fasting. Research shows that fasting may increase vagal tone as well. Fasting may sound intimidating but it is easily accomplished by simply eating dinner around 6-7pm and then not eating again until breakfast at 7 or 8am – that’s a 13-14 hour fast right there! Or you can compress your eating into an 8-10 hour window, say 9am-7pm, for an even longer fast. (25)

There are many different ways to stimulate your vagus nerve. choose 2-3 things that work for you, and make them daily habits by tying them to things you do anyway. If you brush your teeth daily, gargle before or after. If you heat water for coffee or tea daily, hum or sing to yourself while you do it. Make new habits simple, and you’ll integrate them with ease.

The beneficial effects of increased vagal nerve function are so far-reaching that it is more than worthwhile for all of us to add some of these new habits into our daily lives.

Imagine feeling more calm and centered – stimulating your vagus nerve is a great place to start. Choose one or two of these options and start today!


via Hack Your Vagus Nerve to Feel Better: 14 Easy Ways – Victoria Albina

, , , , ,

Leave a comment

[I/Ep] Strategies to Cope With Behavior Changes After Acquired Brain Injury – Archives of Physical Medicine and Rehabilitation

First page of article

Behavior changes are common after acquired brain injury (ABI) because the brain processes information differently after the injury. About 62% of people with ABI experience behavior changes.1 For some people with ABI, the changes in behavior have a major effect on their daily lives, while for others they may be relatively small. These changes can make daily tasks and social interactions difficult. People with ABI may be more sensitive to stress and fatigue, which can make the behaviors described in this article worse.

Full Text HTML

via Strategies to Cope With Behavior Changes After Acquired Brain Injury – Archives of Physical Medicine and Rehabilitation

, , , , , , , ,

Leave a comment

[BLOG POST] Shuffled Neurons, and Other Speed Bumps in The Search for Self-Awareness

By Bill Herrin

Self-awareness after a brain injury

Experiences in life make us who we are – they can intrinsically change who we are for better or worse, sometimes in a temporary way, and sometimes for the rest of our lives. There are things that happen that we’ll cherish, things we look back on and laugh about, things that we’d rather not think about…and then there are things that we won’t even recall. TBI can be like a thief in the night…slipping away with treasured memories and leaving us with little to work with. But take heart, because as the old saying “time heals all wounds” actually rings true, especially in the realm of brain injury. When a brain is injured, the severity really depends on where the injury occurred, the level of the impact, and to some degree – whether the trauma was over the line of being able to overcome or not…not to mention that every person’s brain is as different as their TBI.

Every TBI is Personal

The different levels of self-awareness that arise from having a TBI can spark debate because everyone’s TBI is personal to them, but their self-awareness will never be exactly like someone else’s…although there will be common similarities. That’s where we should focus – on the broad similarities that we can all relate to, and support each other in. For survivors and their friends, families and beyond, there can be friction – often caused by the survivor saying “I don’t need help, I’ll be fine” to someone telling a survivor “you don’t look injured, you’ll be fine.” That’s a hard pill to swallow, especially when the survivor has isolated themselves or if their family has withdrawn from trying to encourage or help them because of previous resistance.

Self-Awareness Doesn’t Come Easy

Awareness of how you’ve changed after a TBI may be harder to do than many realize. I’ll be referencing some points regarding self-awareness from a Lash & Associates “tip card” (an 8-page brochure that they sell) that is packed with great advice for survivors, therapists, clinicians, families, and caregivers. These excerpts will be highlighted in italics.

Why is Self Awareness Important?

Self-awareness is the ability to view ourselves somewhat objectively. It is also the ability to see ourselves from the perspective of other people. It allows us to use feedback from others as we develop our personal identity. We rely on self-awareness when we…

  • interact socially with others
  • decide what situations or information to share
  • make judgments about ourselves, and
  • act in ways that ensure our personal safety.

Brain injury can impair the critical capacity for self-awareness.”

The previous sentence says so much because impairments in self-awareness come from different causes, and can show up at any time – and every person with a TBI will have different impairments or limitations of varying degrees. Hence, their own ability to assess their self-awareness is negligible in many cases. Damage in different parts of the brain can impair self-awareness in ways other than judgment – such as awareness of paralysis of certain parts of the body, awareness of loss of memory, problem-solving skills, reasoning, or being unable to anticipate consequences of decisions (based, in part, by lack of recall of it happening at a prior point in time, etc.)

“What Helps Unawareness?

Working on awareness can help people make better decisions. Efforts to increase a person’s understanding of abilities/disabilities must be done in a manner that preserves self-esteem. A healthy sense of self is critical for recovery. The two primary methods to address impaired self-awareness are education and structured feedback.

Both require an interpersonal bond between the person delivering information or feedback and the individual with impaired self-awareness. It is also important to have an environment that helps the person learn about strengths and weaknesses while still maintaining hope.”

The deficits of self-awareness can be obvious to family, friends, caregivers, and clinicians, and many times be quite frustrating. Helping a survivor to have a clear vision of their actual cognitive and physical abilities should be addressed with patience, positivity, and prudence.

“The goal of feedback is to orient individuals to the aspects of their performance that they do not accurately perceive. It is very important to balance feedback for problem areas with feedback for strengths.

Regardless of the approach used to help someone increase self-awareness, the person in the role of therapist, coach or caregiver needs to have a positive bond or connection with the individual. In order for a person to accept feedback, the person needs to feel that there is a partnership. The clinical term for this partnership is therapeutic alliance.”

In closing, it’s important to realize that everyone has the potential for unrealistic self-awareness – it’s what the long-running TV show “American Idol” was built upon…people whose self-awareness about their vocal abilities may have been bolstered by false praise, or just delusions of grandeur…many times, the people that go on the show with a humble approach are the ones that blow the judges away!!

Help your friend, colleague, partner, family member achieve a realistic understanding of where they are, but help foster a vision for them that will lead them to further improvements through encouragement, suggestions, positivity, strong communication, realistic goals, and love. Dealing with a huge change in self-awareness is complex and there is no “set route” to get to the next level. Understanding this helps both the caregiver and the survivor to make progress on the best terms possible.

The tip card “Changes in Self Awareness” is written by written by McKay Moore Sohlberg, Ph.D. and is available for just $1.00 at  – it’s a great resource for families or clinicians.

via Shuffled Neurons, and Other Speed Bumps in The Search for Self-Awareness

, , , , , , , , ,

Leave a comment

[WEB SITE] TBI and PTSD: Navigating the Perfect Storm – BrainLine

Marilyn Lash, MSW, Brain Injury Journey magazine
TBI and PTSD: Navigating the Perfect Storm

So often people talk about the effects of traumatic brain injury or the consequences of post-traumatic stress disorder as separate conditions — which they are. But for the person who is living with the dual diagnosis of TBI and PTSD, it can be hard to separate them.

Just as meteorologists predict “the perfect storm” when unusual and unprecedented conditions move in to create catastrophic atmospheric events, so can the combination of PTSD and TBI be overpowering and destructive for all in its path. The person with TBI and PTSD is living in a state unlike anything previously experienced. For the family, home is no longer the safe haven but an unfamiliar front with unpredictable and sometimes frightening currents and events.

While awareness of PTSD has greatly increased with recently returning service members and veterans, it is not new and nor limited to combat. Anyone — children, adolescents, adults, elderly — who is exposed to a life-threatening trauma can develop PTSD. Car crashes, shootings, floods, fires, assaults, or kidnapping can happen to anyone anywhere. But the rate of PTSD after brain injury is much higher in veterans than civilians due to their multiple and prolonged exposure to combat. According to O’Connor and Drebing, it is estimated that up to 35% of returning veterans with mild brain injury also have PTSD.

What’s unique about PTSD?

Symptoms of PTSD include:

  • Unwanted and repeated memories of the life-threatening event
  • Flashbacks where the event is relived and person temporarily loses touch with reality
  • Avoidance of people, places, sights, or sounds that are reminders
  • Feelings of detachment from people, even family, and emotional numbness
  • Shame about what happened and was done
  • Survivor guilt with loss of friends or comrades
  • Hypervigilance or constant alertness for threats.

Individuals with PTSD are at increased risk for depression, physical injuries, substance abuse, and sleep problems, which in turn can affect thoughts and actions. These risk factors also occur with brain injury.

PTSD is a mental disorder, but the associated stress can cause physical damage. TBI is a neurological disorder caused by trauma to the brain. It can cause a wide range of impairments and changes in physical abilities, thinking and learning, vision, hearing, smell, taste, social skills, behaviors, and communication. The brain is so complex, the possible effects of a traumatic injury are extensive and different for each person.

When PTSD and TBI coexist, it’s often difficult to sort out what’s going on. Changes in cognition such as memory and concentration, depression, anxiety, insomnia, and fatigue are common with both diagnoses. One basically feeds and reinforces the other, so it’s a complicated mix — it’s the perfect storm. It may help to consider and compare changes commonly seen with TBI and PTSD.


TBI: A period of amnesia for what went on just before (retrograde amnesia) or after (anterograde amnesia) the injury occurred is common. The length of time (minutes, hours, days, or weeks) of amnesia is an indicator of the severity of the brain injury. For example, the person may have no memory of what happened just before or after the car crash or IED explosion.

PTSD: In contrast, the person with PTSD is plagued and often haunted by unwanted and continuing intrusive thoughts and memories of what happened. The memories keep coming at any time of day or night in such excruciating detail that the person relives the trauma over and over again.


TBI: Sleep disorders are very common after brain injury. Whether it is trouble falling asleep, staying asleep, or waking early, normal sleep patterns are disrupted, making it hard to get the restorative rest of sleep so badly needed.

PTSD: The mental state of hypervigilance interferes with slowing the body and mind down for sleep. Nightmares are so common with PTSD that many individuals dread going to bed and spend long nights watching TV or lying on the couch to avoid the night’s terrors. Waking up with night sweats so drenching that sheets and clothing are soaked. Flashbacks so powerful that bed partners have been struck or strangled while sleep battles waged.


TBI: Many survivors of TBI recall the early support and visits of friends, relatives, and coworkers who gradually visited or called less often over time. Loss of friends and coworkers leads to social isolation, one of the most common long-term consequences of TBI.

PTSD: The isolation with PTSD is different as it is self-imposed. For many it is simply too hard to interact with people. The feeling of exposure outside the safe confines of the house is simply too great. The person may avoid leaving the house as a way of containing stimuli and limiting exposure to possible triggers of memories. As a result, the individual’s world becomes smaller and smaller.


TBI: When the areas of the brain that control emotions are damaged, the survivor of a TBI may have what is called “emotional lability.” This means that emotions are unpredictable and swing from one extreme to the other. The person may unexpectedly burst into tears or laughter for no apparent reason. This can give the mistaken impression that the person is mentally ill or unstable.

PTSD: Emotional numbness and deadened feelings are a major symptom of PTSD. It’s hard for the person to feel emotions or to find any joy in life. This emotional shutdown creates distance and conflicts with spouses, partners and children. It is a major cause of loss of intimacy with spouses.


TBI: Cognitive fatigue is a hallmark of brain injury. Thinking and learning are simply harder. This cognitive fatigue feels “like hitting the wall,” and everything becomes more challenging. Building rest periods or naps into a daily routine helps prevent cognitive fatigue and restore alertness.

PTSD: The cascading effects of PTSD symptoms make it so difficult to get a decent night’s sleep that fatigue often becomes a constant companion spilling over into many areas. The fatigue is physical, cognitive, and emotional. Feeling wrung out, tempers shorten, frustration mounts, concentration lessens, and behaviors escalate.


TBI: Depression is the most common psychiatric diagnosis after brain injury; the rate is close to 50%. Depression can affect every aspect of life. While people with more severe brain injuries have higher rates of depression, those with mild brain injuries have higher rates of depression than persons without brain injuries.

PTSD: Depression is the second most common diagnosis after PTSD in OEF and OIF veterans. It is very treatable with mental health therapy and/or medication, but veterans in particular often avoid or delay treatment due to the stigma of mental health care.


TBI: Rather than appearing anxious, the person acts as if nothing matters. Passive behavior can look like laziness or “doing nothing all day,” but in fact it is an initiation problem, not an attitude. Brain injury can affect the ability to initiate or start an activity; the person needs cues, prompts, and structure to get started.

PTSD: Anxiety can rise to such levels that the person cannot contain it and becomes overwhelmed by feelings of panic and stress. It may be prompted by a specific event, such as being left alone, or it can occur for no apparent reason, but the enveloping wave of anxiety makes it difficult to think, reason or act clearly.

Talking about the Trauma

TBI: The person may retell an experience repetitively in excruciating detail to anyone who will listen. Such repetition may be symptomatic of a cognitive communication disorder, but it may also be due to a memory impairment. Events and stories are repeated endlessly to the frustration and exasperation of caregivers, friends, and families who have heard it all before.

PTSD: Avoidance and reluctance to talk about the trauma of what was seen and done is a classic symptom of PTSD, especially among combat veterans.


TBI: Damage to the frontal lobes of the brain can cause more volatile behavior. The person may be more irritable and anger more easily, especially when overloaded or frustrated. Arguments can escalate quickly, and attempts to reason or calm the person are often not effective.

PTSD: Domestic violence is a pattern of controlling abusive behavior. PTSD does not cause domestic violence, but it can increase physical aggression against partners. Weapons or guns in the home increase the risks for family members. Any spouse or partner who feels fearful or threatened should have an emergency safety plan for protection.

Substance Abuse

TBI: The effects of alcohol are magnified after a brain injury. Drinking alcohol increases the risks of seizures, slows reactions, affects cognition, alters judgment, interacts with medications, and increases the risk for another brain injury. The only safe amount of alcohol after a brain injury is none.

PTSD: Using alcohol and drugs to self-medicate is dangerous. Military veterans drink more heavily and binge drink more often than civilian peers. Alcohol and drugs are being used often by veterans to cope with and dull symptoms of PTSD and depression, but in fact create further problems with memory, thinking, and behavior.


TBI: Suicide is unusual in civilians with TBI.

PTSD: Rates of suicide have risen among veterans of OEF and OIF. Contributing factors include difficult and dangerous nature of operations; long deployments and multiple redeployments; combat exposure; and diagnoses of traumatic brain injury, chronic pain, post-traumatic stress disorder, and depression; poor continuity of mental health care; and strain on marital and family relationships. Veterans use guns to commit suicide more frequently than civilians.


There is no easy “either/or” when it comes to describing the impact of TBI and PTSD. While each diagnosis has distinguishing characteristics, there is an enormous overlap and interplay among the symptoms. Navigating this “perfect storm” is challenging for the survivors, the family, the caregivers, and the treatment team. By pursuing the quest for effective treatment by experienced clinicians, gathering accurate information, and enlisting the support of peers and family, it is possible to chart a course through the troubled waters to a safe haven.


O’Connor, M. & Drebing, C. (2011). Veterans and Brain Injury. In Living Life Fully after Brain Injury: A workbook for survivors, families and caregivers, Eds. Fraser, Johnson & Bell. Youngsville, NC: Lash & Associates Publishing/Training, Inc.

Ehde, D. & Fann, J. (2011). Managing Depression, Anxiety, and Emotional Challenges. In Living Life Fully after Brain Injury: A workbook for survivors, families and caregivers, Eds. Fraser, Johnson & Bell. Youngsville, NC: Lash & Associates Publishing/Training, Inc.

Posted on BrainLine March 7, 2013. Reviewed July 26, 2018.


via TBI and PTSD: Navigating the Perfect Storm | BrainLine

, , , , , , , , , , , ,

Leave a comment

[ARTICLE] Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury – Full Text



Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms.


This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI.


Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms.


The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention— two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills.


Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.

1. Introduction

Each year, emergency departments treat approximately 2.5 million traumatic brain injuries (TBIs) (). TBI can affect a wide range of brain systems, resulting in sensorimotor deficits (e.g., coordination, visual perception), cognitive deficits (e.g., memory, attention), emotional dysregulation (e.g., irritability, depression), and somatic symptoms (e.g., headache, fatigue) (). These TBI-related impairments can have significant life consequences. Studies conducted across a wide range of neurological and psychiatric conditions show that neuropsychological abilities are strongly associated with functional skills and employment outcomes (). For example, challenges in attention and concentration could result in distractibility and errors in work settings, and deficits in executive functions could lead to poor organization and problems with setting and achieving occupational goals. As many as 3.2–5.3 million people in the US are living with TBI-related disability ().

Rehabilitation has been shown to improve outcomes for those experiencing chronic effects of TBI (). Previously-validated rehabilitation approaches for TBI include both ‘cognitive’ and ‘functional’ approaches. ‘Cognitive’ methods of rehabilitation are focused on improving performance on individual cognitive tasks, with the hope that these gains will generalize to functional activities (). Restorative cognitive training approaches have been shown to improve cognitive functioning across multiple conditions such as schizophrenia, traumatic brain injury, and normal aging (). Some of the most promising results to date have been demonstrated for training of attention and working memory, which have been shown to correspond to changes in functional brain activity (). Evidence suggests that the format of therapist-guided rehabilitation is able to harness some of the well-established benefits of the therapeutic relationship, and may be preferable to computer-guided training (). While there is some evidence indicating that benefits of cognitive remediation extend to untrained tasks, a number of studies have shown that improvements in performance on individual cognitive tasks tend to generalize very weakly, if at all, to other cognitive tasks and functional abilities (). This weak transfer of training might be attributable to low levels of correspondence between the cognitive and sensorimotor demands of rehabilitation tasks and those encountered during challenging real-world situations.

In contrast to methods of rehabilitation that rely upon generalization of cognitive benefits to functional outcomes, ‘functional’ methods of rehabilitation focus on improving performance on real-life activities through direct practice of those activities (). This approach requires effective targeting of specific functional tasks that are relevant to each patient and may be limited by the physical environments available within the treatment setting (e.g., a simulated home environment used to practice activities of daily living). However, the basic functional tasks that are often emphasized in functional rehabilitation (e.g., self-care, food preparation) may not be sufficiently challenging to address more subtle or ‘higher order’ cognitive and functional deficits that many mild to moderate TBI patients experience in the long-term phase of recovery ().

Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation (). The guiding concept for VR rehabilitation is to provide an immersive, engaging, and realistic environment in which to practice cognitive, sensorimotor, and functional skills. VR scenarios can simulate a wide range of real or imagined tasks and environments. While VR may not be necessary for tasks that are easily recreated in existing therapy environments, it is particularly well-suited for tasks that are challenging or dangerous to recreate within real-world treatment environments, such as driving an automobile ().

Driving is one of the most universal, cognitively challenging, and potentially-dangerous activities of everyday life. Safe driving requires continuous synchronization of processes like reaction time, visuo-spatial skills, attention, executive function, and planning (). Whereas it would be obviously unsafe to place an impaired patient into many real-world driving situations, VR allows for safe assessment and rehabilitation of driving-relevant skills at the true limits of the individual’s current capabilities. Individuals with TBI are at elevated risk for motor vehicle accidents and other driving difficulties (). Many individuals with severe TBI never return to driving (), and an estimated 63% of those with severe TBI who do return to driving are involved in motor vehicle accidents (). Available evidence suggests that deficits in attention and visual search may underlie these driving impairments. While most of this research has been conducted with moderate-to-severe TBI populations, these issues are not exclusive to severe forms of TBI. Individuals recovering from mild TBI have also been found to exhibit slower detection of driving hazards in simulated driving experiments () and to be at increased risk for real-world motor vehicle accidents ().

Previous results suggest that VR driving rehabilitation can be effective for improving driving skills among those with moderate-to-severe TBI (). However, these findings have not been replicated or validated for those with symptomatic mild TBI. Additionally, little is known about the effectiveness of VR rehabilitation programs for TBI-related cognitive deficits (). In response to these clinical and research gaps, we developed an intervention known as Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), which was designed to improve cognitive performance and overall driving safety by providing integrated training in these skills. In contrast to intervention approaches that are geared toward more severely impaired individuals, NeuroDRIVE was designed for use with a wide range of TBI patients (i.e., mild, moderate, or severe TBI) who are seeking treatment in these areas and have the capability to engage in the driving process. This pilot clinical trial examined feasibility and preliminary efficacy of NeuroDRIVE for improving VR driving performance, cognitive performance, and symptom outcomes among those with chronic TBI. Given the focus of the intervention, effects on attention and working memory were of particular interest. Additionally, we have provided the NeuroDRIVE treatment manual as a supplementary document to facilitate continued development of VR rehabilitation for those with TBI.



Continue —-> Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury

An external file that holds a picture, illustration, etc.Object name is nre-44-nre192718-g002.jpg

T3 VR Driving Simulator.

, , , , , , , , , , ,

Leave a comment

[WEB SITE] PTSD Anger, Irritability and Other Symptoms People Don’t Understand

13 ‘Impolite’ Things People With PTSD Do


Living with difficult PTSD symptoms day-in-and-day-out can sometimes make us act in ways others don’t understand. Unfortunately, some folks perceive behavior they don’t understand as being “impolite” — even when that couldn’t be further from the truth.

Maybe you struggle with physical contact in the wake of physical or sexual trauma — and your family members think you’re rude for refusing hugs. Maybe you struggle to make eye contact, and people think you aren’t interested in what they have to say. Or maybe you lash out in anger at loved ones when you’re feeling especially stressed.

If you struggle with an “impolite” manifestation of PTSD, we want you to know you’re not alone. The only way we can set the record straight about “impolite” things people do because of PTSD is to talk about it. To open up this discussion, we asked our Mighty community to share one “impolite” thing they do because of PTSD.

Here’s what our community had to say:

1. Not Responding in Conversations

“I’m accidentally anti-social. I dissociate in times of fear and stress. When I’m aware that I’m experiencing dissociation, I feel a warm fuzz come over my body. My surroundings don’t feel real. It’s harder to move and harder to speak. I’m not trying to be impolite… I’m just… stuck!” — Melissa T.

2. Leaving Events Early or Canceling Last-Minute

“I go home. I leave early, I leave big events, I leave when I want to stay — because I can only handle so much. I wish people knew I left because I felt like I needed to. I wanted to stay.” — Brittany P.

“Tell people yes to coming to events or friend outings and cancel last-second because I can’t pull myself together. I’m sure they assume I just don’t care, but it breaks my heart. It steals so many precious memories from me.” — Erin C.

3. ‘Ghosting’ Your Friends

I repetitively ghost my friends by not answering their messages and calls. I don’t want to rely on people too much or bond with them because my PTSD tells me intimacy is unsafe.” — Kareline E.

4. Lashing Out at Others

“Lashing out under immense stress.” — Harmony Y.

I’m not sure if it’s PTSD or anxiety — I get very short or sometimes aggressive with customer service people on the phone when I need to discuss a problem. Partly from the fear/stress of making a phone call and partly from a perceived injustice. This is (hopefully) different from simply being an aggressive, nasty person — I am usually very empathetic and considerate.” — John S.

There comes a point where my anger at having to go through all this crap and living with this constant tension reaches the limit, and I unload on the unfortunate soul who just put the last straw on my back. I don’t pity bullies, and when the latest one crosses me, it’s on. I don’t lose control of my anger, but I get on the mountaintop and throw out a big sermon.” — Amanda C.

5. Refusing Physical Affection

I hate hugs. Get off me! Respect the bubble. I do the one-armed pat on the back thing. Some people get offended by that and say something, some know it’s just how I roll.” — Megan G.

6. Seeming ’Unapproachable’

“I work nights at a hotel. I don’t smile a lot because I don’t want to seem too inviting.” — Emily S.

7. Running Away

“I can be difficult about certain things. Parking for instance. I also race across the parking lot in stores and stuff leaving people behind. They think I’m being rude. I have PTSD from being run over by a car.” — Liz T.

8. Being Uncooperative With Doctors

“I’m especially uncooperative with doctors. I need to know  I have control over my health care decisions and especially my body, so I tend to shut down and flat-out ignore them the second I feel threatened by their recommendations or approach. I make them work harder to come up with a solution by refusing to allow them to touch me at times. I just want them to listen first before assuming they have consent because I opted to be their patient. Fortunately, I now have a team that is open to working within my comfort level and continues to support me when I allow myself to be vulnerable with them, even when I respond negatively.” — Kristen P.

9. Avoiding Family Members

I avoid events with other family members that don’t try and understand after many times of explaining. I don’t like being put on the spot or even want to talk to anyone so ‘impolite’ is a nice way of saying rude. I’m just rude (in their eyes) because I don’t care anymore won’t go to Thanksgiving, social outings, etc. I don’t like to be around anyone at all. And I’m actually OK with that.” — Rebecca J.

10. Relying on a Friend or Partner to Speak for You

“I look at my phone to avoid contact of any kind. Or I hide behind my boyfriend so he can do the talking.” — Ember H.

“Ignore people and rely on my partner to ‘human’ for me. She’s a champion, at least with her I don’t have to say anything, she just understands and reads me at a glance to know when I’m not coping.” — David C.

11. Telling People to Stop Talking to You

“Telling people to please just shut up and do not touch me. To be honest, I do not think it is such an impolite thing to do, I find it more impolite by others to insist on touching and trying to rush me when I have flashbacks or a bad moment and am in pain and am just trying to get some space and air to breathe… but others, unfortunately, seem to perceive it as quite impolite.” — Leila B.

“Sometimes I go into sensory overload and can no longer process things — especially when people ask a ton of questions in a row! So I have to say I can’t handle any more questions at the moment.” — Briana W.

12. Not Making Eye Contact

“Making eye contact. I don’t like people grabbing my arms or touching me at all actually. So makes me seem pretty impersonal.” — Jolene F.

13. Oversharing

“I overshare. Every single person in my life knows my situation, from my boss to some kid I went to school with. They also know my every mood and difficulty. Secrecy led to 15 years of me being incestuously molested, so anything that feels like secrecy or me being told to be quiet or not speak triggers me and produces the opposite — I positively shout things out to everyone now. I know it’s not ‘polite’ to overshare, but being in a situation where I’d be used again terrifies me.” — Peta J.

Though some of these behaviors might seem “impolite” to people who don’t understand, we want to remind you it’s more than OK to set boundaries. If you don’t like to be touched, you’re not rude for requesting people not touch you. If you need to take a breather in social situations, take a breather! You deserve to make decisions about what’s best for you.

For support from a community that really understands, you can always post on The Mighty with the hashtag, #CheckInWithMe. PTSD can feel isolating, but you don’t have to go it alone. Join The Mighty community and find the support you need.

What “impolite” thing does your PTSD make you do?


via PTSD Anger, Irritability and Other Symptoms People Don’t Understand | The Mighty

, , , , , , , , , , ,

Leave a comment

[VIDEO] RehaCom introduction – YouTube

RehaCom is a modular software used for cognitive therapy. It assists therapist in the rehabilitation of cognitive disorders that affect specific aspects of attention, concentration, memory, perception, activities of daily living and much more.


, , , , , , , ,

Leave a comment


Cognitive behavioral therapy facts - Dr. Axe

, ,

Leave a comment

%d bloggers like this: