diagnosing brain injurylecture3

JESSICA D. RICHARDSON, PH.D. , CCC-SLP

Role of the Speech-Language Pathologist in the Recovery Process of

Individuals with Traumatic Brain Injury

ASHA Scope of Practice

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

http://www.asha.org/uploadedFiles/SP2007-00283.pdf

http://www.asha.org/uploadedFiles/SP2007-00283.pdf

Narrative Samples

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.

www.asha.org/policy/

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

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

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

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.

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.

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.…

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

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?

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

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

http://tbims.org/combi/list.html

http://tbims.org/combi/list.html

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 observationi. To confirm and enrich OR negate test findingsii. Why?

4 - Assessment (3)

3. Ongoing contextualized hypothesis testingi. 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?

4 - Assessment (4)

4. Measure the knowledge and support skills of the people in the everyday life of the person with TBI

4 - Assessment (5)

5. Collaboration with other professionals6. Collaboration with the patient

i. Collaborating with the patient in the following is important for both assessment and treatment:

i. Goal-settingii. Testing intervention hypothesesiii. Exploring strategic compensationsiv. Monitoring outcomes

ii. Evidence that direct patient involvement in neurorehabilitation goal setting => maintained goals at follow-up

PatientPatient

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.

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

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

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) http://www.rancho.org/research/cognitive_levels.pdf

http://www.rancho.org/research/cognitive_levels.pdf

5 - Determine Intervention Approach

Differential DiagnosisComorbid DiagnosesLimitations and Contextual FactorsHierarchy of Clinical Importance/Personal

Importance The “whole picture” Prioritize immediate and less-immediate needs

6 – Intervention

To discuss

7 - Re-assessment

Remember, assessment should be ongoingAlso, the final stage of evidence-based

practice is to evaluate whether or not the chosen approach is working and to make modifications as necessary.

6 – Intervention

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

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

TBI and COMMUNICATION

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.


Low incidence of aphasia secondary to TBICommunication 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


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


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






breakdowns and repairing More turns of shorter and less complex utterances








breakdowns and repairing Shorter and less complex utterances




EBRsPractice Standards

Cognitive-linguistic therapy Acute, postacute

Intervention to improve social communication skillsPractice Guidelines

Intervention for specific areas of deficit (e.g., reading, word-finding, narrative production)

Treatment intensity is a key factorPractice Options

Group-based intervention for language and social-communication deficits

Computer-based interventions as an adjunct to clinician-guided treatment of cognitive-linguistic deficits


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

TBI and EXECUTIVE FUNCTION

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

FRONTAL LOBE FUNCTIONS (1)

4 Functional Domains1. Executive2. Behavioral/Emotional Self-regulatory3. Energization regulating4. Metacognitive


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


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

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

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

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)

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

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

TBI and ATTENTION

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

Attention (2)LEVELS AND TYPES

FUNCTION ASSESSMENT

AROUSAL State of consciousness; primitive wakefulness

Gross motor response to sensory stimulation

AWARENESS Assumes arousal; from stupor to clear perception of surroundings

Answer questions

SELECTIVE ATTN Focus; resistance to distraction; managing limited resources by selection

Two stimuli or tasks; response to one

SUSTAINED ATTN Vigilance or concentration; maintaining focus on one stimulus for a period of time

A series of stimuli and response to one

DIVIDED ATTN Allocating 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

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

Attention (4)

Sensory selective attentional system Rarely damaged relative to other systems If damaged, => object recognition difficulty, unilateral spatial

neglectArousal, sustained attention and vigilance system

Commonly damaged If damaged, => decreased perceptual sensitivity/decreased

vigilanceAnterior 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,

Attention (5)

EBRsPractice 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

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

TBI and MEMORY

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

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)

MEMORY (3)

EBRsPractice 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

TREATING THE WHOLE PATIENT

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

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

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

Pediatric TBI and Academic Re-entry

Community Integration and Vocational Rehabilitation

TBI and disorders of mood, affect, and motivation

TBI and psychosocial factors

diagnosing brain injurylecture3

Documents

individual limitations

limitations of body

assessment information

c c c s

terms of resultant limitations

quality of assessment

pretbi life activities

limitation of body structure