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JESSICA D. RICHARDSON, PH.D., CCC-SLP Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury.

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Presentation on theme: "JESSICA D. RICHARDSON, PH.D., CCC-SLP Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury."— Presentation transcript:

1 JESSICA D. RICHARDSON, PH.D., CCC-SLP Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury

2 ASHA Scope of Practice ASHA = American Speech-Language-Hearing Association  Scope of practice:

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6 Narrative Samples

7 Functional outcomes and reimbursement trends Trend of reduced resources available for rehabilitation Trend of increased demands for improved functional outcomes  Lessening activity/participation limitations is focus instead of traditional focus of eliminating/reducing the underlying impairment.  Treatment effectiveness is therefore demonstrated by meaningful improvements in the tasks of everyday life.

8 Functional outcomes and WHO-ICF World Health Organization – International Classification of Functioning, Disability, and Health (WHO-ICF)  Classification system that describes disorders in terms of resultant limitations placed upon the individual  Limitations in body function and structure  Activity limitations  Participation limitations  Contextual factors

9 WHO-ICF: Limitations in body structure/function Previously known as “impairment” Underlying damage to psychological, physiological, or anatomic structures or functions  e.g., inability to hold more than 6 items in memory, increased distractibility, word-finding deficits/anomia

10 WHO-ICF: Activity limitations Previously known as “disability” Functional consequences of the limitations of body function and structure  e.g., limitation of body structure and function = anomia/word-finding problem; resultant activity limitation = unable to add ideas or take turns in conversation Predictive of participation limitations

11 WHO-ICF: Participation limitations Previously known as “handicap” Tied to one’s well-being and social consequences that arise from having cognitive disorder; discussed relative to life roles  e.g., Can the individual with a TBI still lead meetings, conduct class lessons, drive a truck (long-haul), etc.? If not, then participation in pre-TBI life activities is limited.

12 WHO-ICF: Contextual factors Social, familial, educational, vocational, or other role disadvantage associated with the disability  e.g., failure in school, loss of job Includes also:  Environmental factors  factors not within the person’s control (e.g., attitudes of individuals in the environment, family, work, government agencies, laws, cultural beliefs, etc.)  Personal factors  e.g., attitudes of individual with TBI, race, gender, age, educational level, coping styles, etc.

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16 Flow of clinical services 1 - Pre-assessment. 2 - The development of a clinical question regarding diagnosis, intervention, and/or discharge. 3 - Selection of assessment instruments. 4 - Assessment. 5 - Using the information to determine intervention approach. 6 - Intervention. 7 - Re-assessment. …

17 1 - Pre-assessment Thorough pre-assessment improves quality of assessment process and information gained Especially important in TBI  history, substance abuse, depression, etc. Sources of pre-assessment information can include:  Written case history  Interview with client and caregivers  Who is concerned about the client’s communication performance (client, other health professional, family member, etc.)? Why are they concerned?  Interview/Information from other professionals, Medical records

18 2 - Development of clinical question This is also Step 1 of evidence-based practice: “The development of a clinical question regarding diagnosis, intervention, and/or discharge.”  Does the person potentially have a disorder that falls under my scope of practice?  If yes, what domains seem to be affected?  What additional information do I need to obtain in order to have sufficient information for determining if the person actually has one or more disorders?

19 3 – Selecting your assessment measures Before using a standardized assessment measure, need to determine whether or not it is the appropriate measure to administer.  What is the purpose of the test?  How was the test constructed/developed?  What are the administration and scoring procedures?  What is the normative sample group?  Is this a valid test?  Is this a reliable test?  Which domain of WHO-ICF limitations does this test assess? Will also need to use nonstandardized assessment measures

20 4 - Assessment (1) Traditionally, assessment has involved:  Battery of tests of neuropsychological/cognitive/linguistic function to identify strengths and weaknesses (i.e., limitations of body structure/function) Improved approach includes contextualized measures (aka “authentic” measures)  Arose because research has demonstrated that aforementioned assessment approach does a poor job assessing functional, real-world outcomes and/or long-term maintenance of treatment gains and does not assist with vocational planning

21 4 - Assessment (2) 1. Standardized tests to identify deficits and to generate hypotheses about areas to target in rehabilitation 1. *comment on aphasia batteries for TBI 2. Situational observation i. To confirm and enrich OR negate test findings ii. Why?

22 4 - Assessment (3) 3. Ongoing contextualized hypothesis testing i. Systematic exploration of strategies, task modifications, supports, intervention procedures, etc. that could positively influence task performance and learning ii. Why ongoing and contextualized? iii. Why hypothesis testing?

23 4 - Assessment (4) 4. Measure the knowledge and support skills of the people in the everyday life of the person with TBI

24 4 - Assessment (5) 5. Collaboration with other professionals 6. Collaboration with the patient i. Collaborating with the patient in the following is important for both assessment and treatment: i. Goal-setting ii. Testing intervention hypotheses iii. Exploring strategic compensations iv. Monitoring outcomes ii. Evidence that direct patient involvement in neurorehabilitation goal setting => maintained goals at follow-up

25 Patient Big Picture Rehabilitation Coordinator/Case Manager Primary Physician Neuropsychologist Psychologist Medical Consultants Social Worker Recreation Therapist Vocational Specialist Nurse Physical Therapist Nutritionist Speech Pathologist Occupational Therapist Source: Christine C. O’Hara and Minnie Harrell, Rehabilitation with Brain Injury Survivors: An Empowerment Approach, Aspen Publishers, Inc., 1991.

26 4 - Assessment (6) Why are all of these team members involved?  Primary Consequences Penetrating Head Injury (Low-velocity, High-velocity) Nonpenetrating (or closed) Head Injury (Nonacceleration, Acceleration [linear, angular]) Diffuse Axonal Injury  Some Secondary Consequences (brain’s responses to primary trauma, often more devastating than primary consequences) Traumatic hemorrhage, cerebral edema, traumatic hydrocephalus, increased intracranial pressure, ischemic brain damage, cerebral vasospasm  Resultant Systemic complications Skin, eye, ear, nose, mouth and throat, larynx, trachea, lungs, GI tract, heart, PVS, genitourinary system, female reproductive system, metabolic-endocrine system, blood, musculoskeletal system, PNS, CNS

27 4 - Assessment (7) Assessment and Intervention Environments  Acute setting  Post-acute/sub-acute facilities  Day treatment/outpatient services  Group home/residential living  Vocational rehabilitation  Transitional living  Protected work trial  School  Private clinic  Behavior management  Pediatric programs  Brain injury + other conditions  Respite

28 4 – Assessment (8) Assessment and Intervention will depend upon stage of recovery, e.g.,  STAGE 1 – “Comatose and Semi-Comatose”  STAGE 2 – “Responsive and Agitated”  STAGE 3 – “Restless and Distractible”  STAGE 4 – “Oriented, Purposeful”  STAGE 5 – “Dependent”  STAGE 6 – “Semi-Independent”  Also, Rancho Los Amigos Levels of Cognitive Functioning (p. 425) 

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30 5 - Determine Intervention Approach Differential Diagnosis Comorbid Diagnoses Limitations and Contextual Factors Hierarchy of Clinical Importance/Personal Importance  The “whole picture”  Prioritize immediate and less-immediate needs

31 6 – Intervention To discuss

32 7 - Re-assessment Remember, assessment should be ongoing Also, the final stage of evidence-based practice is to evaluate whether or not the chosen approach is working and to make modifications as necessary.

33 6 – Intervention

34 EVIDENCE-BASED RECOMMENDATIONS Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group (Cicerone et al., 2011, Arch Phys Med Rehabil)  ATTENTION  VISION and VISUOSPATIAL FUNCTIONING  LANGUAGE AND COMMUNICATION SKILLS  MEMORY  EXECUTIVE FUNCTIONING  COMPREHENSIVE-INTEGRATED NEUROPSYCHOLOGIC REHABILITATION

35 EVIDENCE-BASED RECOMMENDATIONS Practice Standards  At least 1 well-designed Class I study with adequate N  Additional support from Class II or Class III evidence  Directly addresses treatment effectiveness  Substantive evidence of effectiveness Practice Guidelines  1 or more Class I studies with methodologic limitations OR well- designed Class II studies with adequate N  Directly addresses treatment effectiveness  Evidence of probably effectiveness Practice Options  Class II or Class III studies  Directly addresses treatment effectiveness  Evidence of possible effectiveness

36 TBI and COMMUNICATION

37 TBI and Communication (1) Speech Impairment – a problem with voice, fluency, and/or how a person says speech sounds. Language Impairment – a problem with understanding and/or using spoken, written, and/or other symbol systems.  Form – the rules about how sounds are combined, how words are constructed, and how we combine words to form sentences.  Content – the meanings of words.  Function – using language (form and content) to communicate in functional and socially appropriate ways.

38 TBI and Communication (2) Low incidence of aphasia secondary to TBI Communication problems secondary to TBI are quite different from aphasia, BUT aphasia assessment batteries are commonly administered  Problem with aphasia test batteries  "Performance on aphasia batteries may give the impression that their communicative skills are intact. However, interactions with many of the same individuals leave the listener with the sense that they are off target, tangential, and disorganized or, in some cases, have very little to say. The overestimated communicative performance of these individuals is a function of the limited scope and ceiling effect of aphasia batteries, which were never intended to assess the subtle types of deficits many individuals with TBI demonstrate.” Coelho et al., 2005, Seminars in Speech and Language Impaired discourse is the hallmark of post-TBI cognitive-communication disorder

39 TBI and Communication (3) Discourse abilities reside at crossroads of language and cognition Anatomy:  Lateral and medial prefrontal cortices (LPFC, MPFC)  Dorsolateral LPFC  Temporoparietal and anterior temporal regions  Posterior cingulate  Connections between these areas, and from these areas to other lobes

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43 TBI and Communication (4) Discourse Impairment  Macro-linguistic deficits  Reduced cohesion and coherence; impaired organization; problems with story components and grammar  Difficulty with inference  Impaired social cognition  Reduced information and efficiency  Tangential language, difficulty identifying communication breakdowns and repairing  Shorter and less complex utterances  Reduced initiation and maintenance  Dependent on others to maintain flow of conversation  Micro-linguistic deficits  Meaning within words, phrases, sentences

44 TBI and Communication (4) Discourse Impairment  Macro-linguistic deficits  Reduced cohesion and coherence; impaired organization; problems with story components and grammar  Difficulty with inference  Impaired social cognition  Reduced information and efficiency  Tangential language, difficulty identifying communication breakdowns and repairing  Shorter and less complex utterances  Reduced initiation and maintenance  Dependent on others to maintain flow of conversation  Micro-linguistic deficits  Meaning within words, phrases, sentences

45 TBI and Communication (4) Discourse Impairment  Macro-linguistic deficits  Reduced cohesion and coherence; impaired organization; problems with story components and grammar  Difficulty with inference  Impaired social cognition  Reduced information and efficiency  Tangential language, difficulty identifying communication breakdowns and repairing  More turns of shorter and less complex utterances  Reduced initiation and maintenance  Dependent on others to maintain flow of conversation  Micro-linguistic deficits  Meaning within words, phrases, sentences

46 TBI and Communication (4) Discourse Impairment  Macro-linguistic deficits  Reduced cohesion and coherence; impaired organization; problems with story components and grammar  Difficulty with inference  Impaired social cognition  Reduced information and efficiency  Tangential language, difficulty identifying communication breakdowns and repairing  Shorter and less complex utterances  Reduced initiation and maintenance  Dependent on others to maintain flow of conversation  Micro-linguistic deficits  Meaning within words, phrases, sentences

47 TBI and Communication (4) Discourse Impairment  Macro-linguistic deficits  Reduced cohesion and coherence; impaired organization; problems with story components and grammar  Difficulty with inference  Impaired social cognition  Reduced information and efficiency  Tangential language, difficulty identifying communication breakdowns and repairing  Shorter and less complex utterances  Reduced initiation and maintenance  Dependent on others to maintain flow of conversation  Micro-linguistic deficits  Meaning within words, phrases, sentences

48 TBI and Communication (5) EBRs Practice Standards  Cognitive-linguistic therapy  Acute, postacute  Intervention to improve social communication skills Practice Guidelines  Intervention for specific areas of deficit (e.g., reading, word-finding, narrative production)  Treatment intensity is a key factor Practice Options  Group-based intervention for language and social-communication deficits  Computer-based interventions as an adjunct to clinician-guided treatment of cognitive-linguistic deficits

49 TBI and Communication (6) Types of tasks  Social skills training  Pragmatic communication behaviors Listening, starting a conversation  Social perception of emotions and social inferences  Psychotherapy for emotional adjustment  Self-instructional training strategies for emotion perception deficits (metacognitive strategies)  Narrative, conversation

50 TBI and EXECUTIVE FUNCTION

51 What are executive functions? Executive functions = “superordinate, managerial capacity for directing more modular abilities, including language, memory, motor skills and perception in the service of managing and attaining goals” (p 487)  Maintenance of a problem-solving set for future goals (working memory)  Set shifting  Planning and problem solving  Decision making based on reward and penalty  Self-regulation

52 FRONTAL LOBE FUNCTIONS (1) 4 Functional Domains 1. Executive 2. Behavioral/Emotional Self-regulatory 3. Energization regulating 4. Metacognitive

53 FRONTAL LOBE FUNCTIONS (2) EFs mediated by frontally guided, distributed networks involving prefrontal subregions, posterior cortex, and subcorticalstructures (e.g., basal ganglia, ventral striatum) 1 – Executive Cognitive Functions  Anatomy – lateral prefrontal cortex (LPFC)  Function Overview – control and direction of lower level/automatic functions  Planning, monitoring, activating, switching, inhibiting 2 – Behavioral/emotional self-regulatory functions  Anatomy – ventral (medial) prefrontal cortex (VPFC)  Function Overview – emotional responsiveness, reward processing, behavioral self-regulation

54 FRONTAL LOBE FUNCTIONS (3) 3 – Energization regulating functions  Anatomy – superior medial frontal lobes, anterior cingulate; frontal cortical-subcortical circuits  Function Overview – capacity to generate and maintain actions important for adequate performance of other functions  Extreme case – abulia, or severe apathy  Most common presentation – slowed reaction time, slowed processing speed 4 – Metacognitive functions  Anatomy – frontal pole (BA 10) (right hemisphere bias?); connections to other regions  Function Overview – integrative aspects of personality, social cognition, consciousness, theory of mind, humor

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58 TBI and Executive Function TBI “arguably the most important single cause of frontal lobe dysfunction” (p 469) The cognitive and behavioral consequences of TBI are the most enduring and have most impact (more than physical).  “The chronic disability of TBI is accentuated by its tendency to take place during early adulthood, affecting behavior for decades.” (p 469) Can occur with both penetrating and non- penetrating TBI

59 Treatment of Frontal Lobe Dysfunction (1) 1 - Executive/cognitive  Problem solving and planning  Problem-solving training (PST)  Working memory training 2 - Behavioral/Emotional Self-regulatory  Treatment targeting “goal neglect” (to bridge gap between intention and action)  Goal management training (GMT)  External aids/cues

60 Treatment of Frontal Lobe Dysfunction (2) 3 - Energization regulating  Pharmacologic intervention  Dopamine agonists, serotonin agonists  External aids/cues 4 - Metacognitive  Deficit awareness  Awareness Intervention Program (AIP)  Error awareness and self-monitoring  Self-monitoring training (SMT)

61 EBRs: EXECUTIVE FUNCTION (1) Practice Standard  Metacognitive strategy training (self-monitoring, self- regulation) for executive functioning and emotional self- regulation  As a component of attention, neglect, and/or memory treatment Practice Guideline  Problem-solving training (everyday situations, functional activities)  Postacute Practice Options  Group-based intervention for executive function and problem- solving

62 EBRs: EXECUTIVE FUNCTION (2) Previous standards, guidelines, options were for adults only There are no established cognitive interventions for children with TBI  Generally, approaches used for LD and ADHD are employed Assessment and treatment of EFs in children is especially complicated, because of the diversity of EFs as well as the differences in developmental trajectories for the different EF processes  Gray and white matter volume, lateralization, and distribution of cognitive control changes with age; “notable shortage” of neuroimaging studies for ped TBI

63 TBI and ATTENTION

64 Attention (1) Multidimensional  Sensory selective attentional system  Parieto-temporo-occipital area  Orienting, engaging, and disengaging attention and object recognition  Arousal, sustained attention and vigilance system  Midbrain reticular activating system and limbic structures  Arousal, sustained attention, vigilance, mood, motivation, salience of stimuli, readiness to respond  Anterior system for selection and control of responses  Frontal lobes, anterior cingulate gyrus, basal ganglia, thalamus  Intentional control and use of strategies for manipulating information, active switching and inhibition

65 Attention (2) LEVELS AND TYPESFUNCTIONASSESSMENT AROUSALState of consciousness; primitive wakefulness Gross motor response to sensory stimulation AWARENESSAssumes arousal; from stupor to clear perception of surroundings Answer questions SELECTIVE ATTNFocus; resistance to distraction; managing limited resources by selection Two stimuli or tasks; response to one SUSTAINED ATTNVigilance or concentration; maintaining focus on one stimulus for a period of time A series of stimuli and response to one DIVIDED ATTNAllocating limited resources to multiple processes or tasks Two stimuli or tasks; response to both (dual task paradigms) Common terms and categorization in testing and treatment

66 Attention (3) TBI => diffuse and bilateral injury to many regions including frontal, temporal, meso-limbic, and midbrain reticular formation areas  These areas are involved in attention  One of most common cognitive complaints post-TBI  Commonly assessed via:  Digit span (e.g., subtest of Wechsler Memory Scale; WMS)  WAIS - Digit symbol coding and symbol digit modalities tests  SART – Sustained Attention and Response Task  TMT – Trail Making Test  BTA – Brief Test of Attention  TEA – Test of Everyday Attention  Attention Questionnaire

67 Attention (4) Sensory selective attentional system  Rarely damaged relative to other systems  If damaged, => object recognition difficulty, unilateral spatial neglect Arousal, sustained attention and vigilance system  Commonly damaged  If damaged, => decreased perceptual sensitivity/decreased vigilance Anterior system for selection and control of responses  Commonly damaged  If damaged, => slower to perform selective and divided attention tasks, impaired speed of information processing (increased RT), distractible,

68 Attention (5) EBRs Practice Standards  Remediation of attention during postacute rehabilitation  Should include direct attention training  Contextualized  Should include metacognitive training to promote development of compensatory strategies and foster generalization to real-world tasks. Practice Option  Computer-based interventions as an adjunct to clinician- guided treatment of attention deficits

69 Metacognitive techniques: Goal definition => Performance predictions => planned strategy use => self-evaluation => self- reflection Role reversal, audio-visual feedback Tasks such as food preparation, laundry, driving, work duties

70 TBI and MEMORY

71 MEMORY (1) Working (and short-term) memory - involved in the acquisition of new information and the activation of old or stored information whenever it is needed for a task; make contact with the knowledge in LTM Long-term memory (LTM)  Retrospective memory – memory for past events and experiences and for information acquired in the past  Declarative memory Episodic memory Semantic memory  Procedural memory  Prospective memory – ability to remember to do things at specific points in time

72 MEMORY (2) TBI => diffuse and bilateral injury to many regions including temporal and basal-frontal regions  These areas are involved in memory  Difficult to separate from attention  Commonly assessed via:  WMS - Wechsler Memory Scale Digit/letter/word span for immediate retention  AMI – Autobiographical Memory Interview  GOAT – Galveston Orientation and Amnesia Test  RBMT – Rivermead Behavioral Memory Test  CAMPROMPT – Cambridge Prospective Memory Test  Corsi Block-tapping Test  Memory for Designs Test (of Stanford-Binet Intelligence Scale)

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74 MEMORY (3) EBRs Practice Standard  Memory strategy training (internalized strategies [e.g., visual imagery], external memory compensations [e.g., notebooks])  Mild memory impairment Practice Guideline  Memory strategy training (with external compensations) with direct application to functional activities  Severe memory impairment Practice Options  Errorless learning for specific skills or knowledge  Severe memory impairment  Evidence of limited transfer/generalization  Group-based intervention

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76 TREATING THE WHOLE PATIENT

77 EBRs: COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION Practice Standard  C-HNR to reduce cognitive and functional disability  Postacute  Moderate to severe TBI Practice Options  Integrated cognitive + interpersonal + comprehensive neuropsychological rehabilitation  Group-based interventions

78 COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION (1) Cicerone et al., 2004, 2008 Outpatient, postacute Comprehensive-Holistic = 16 weeks (15-20 hours/week)  Core treatment  Individual and/or group psychotherapy, family support and involvement, therapeutic work trials, ADLs, assessment of progress, observing videotapes of communication/interaction, feedback to self and others, etc.  Cognitive group treatment  Functional activities with emphasis on executive functioning, metacognitive functioning, interpersonal group processes  Individual cognitive remediation (patient involved in goal setting and content of activities)  Group communication treatment – communication, interpersonal communication style, perspective taking, social behavior, pragmatic language skills Standard = 16 weeks (12-24 hours/week)  Primarily individual, separate sessions of physical, occupational, speech, and neuropsychologic therapy  Also recreational, vocational, and/or educational therapy/intervention, psychologic counseling

79 COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION (2) Comprehensive-Holistic => greater improvements when compared to standard neurorehabiltation program of similar intensity/duration  Twice the magnitude of treatment effects observed in community integration  Also => greater improvements in neuropsychologic functioning  Improvement on complex attention and executive functioning tasks directly related to community integration

80 Pediatric TBI and Academic Re-entry

81 Community Integration and Vocational Rehabilitation

82 TBI and disorders of mood, affect, and motivation

83 TBI and psychosocial factors


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