Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury

1. Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury Jessica D. Richardson, Ph.D., CCC-SLP

2. ASHA Scope of Practice • ASHA = American Speech-Language-Hearing Association • Scope of practice: http://www.asha.org/uploadedFiles/SP2007-00283.pdf

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. www.asha.org/policy/

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.

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

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

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

23. 4 - Assessment (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 • Collaboration with the patient • Collaborating with the patient in the following is important for both assessment and treatment: • Goal-setting • Testing intervention hypotheses • Exploring strategic compensations • Monitoring outcomes • Evidence that direct patient involvement in neurorehabilitation goal setting => maintained goals at follow-up

25. Big Picture Rehabilitation Coordinator/Case Manager Primary Physician Neuropsychologist Nurse Psychologist Patient Medical Consultants Physical Therapist Occupational Therapist Social Worker Recreation Therapist Speech Pathologist Vocational Specialist Nutritionist 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) • http://www.rancho.org/research/cognitive_levels.pdf

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

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