SPA 6417 TBI

▪ Attention and Concentration symptoms of TBI

"A person with TBI may be unable to focus, pay attention, or attend to more than one thing at a time. This may result in: • Restlessness and being easily distracted. • Difficulty finishing a project or working on more than one task at a time. • Problems carrying on long conversations or sitting still for long periods of time. Since attention skills are considered a "building block" of higher level skills (such as memory and reasoning), people with attention or concentration problems often show signs of other cognitive problems as well." (Neumann & Lequerica)

Memory symptoms of TBI

"Persons with TBI may have trouble learning and remembering new information and events. ▪ They may have difficulty remembering events that happened several weeks or months before the injury (although this often comes back over time). Persons with TBI are usually able to remember events that happened long ago. ▪ They may have problems remembering entire events or conversations. Therefore, the mind tries to "fill in the gaps" of missing information and recalls things that did not actually happen. Sometimes bits and pieces from several situations are remembered as one event. These false memories are not lies." (Neumann & Lequerica).

Intervention styles for cognitive decline

- Errorless learning - Implementing positive everyday routines - provide antecedent supports

Assessment of Communication Skills Linguistic Contributors

- Macrolinguistic Processing: Spoken and Written Narrative and Discourse - Microlinguistic Processing: Words and Sentences - Extralinguistic Contributors - Paralinguistic Contributors

Screening:

- Neurobehavioral Cognitive Status Examination (NCSE) or Cognistat - Brief Test of Head Injury (BTHI)

formal cognitive assessments

- Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) - Galveston Orientation and Amnesia Test (GOAT) - The Brief Test of Head Injury (BTHI) - The Ross Information Processing Assessment - Second Edition (RIPA-2) There is a lack of empirical data to support the use of many standardized, norm-referenced tests for individuals with cognitive communication disorders after TBI". -assessment tools were not created to be used on the TBI population. ***Standardized, norm-referenced tests should be administered to the TBI population with extreme caution. - it is common for SLPs to use some of the same assessments commonly used for patients with aphasia on TBI patients

Pragmatics and TBI

- Verbal and nonverbal violations of pragmatic aspects are common - According to Hux, one of the best ways to identify the linguistic, extralinguistic and paralinguistic abilities of a TBI survivor is to observe his/her pragmatic communication skills and deficits (2011).

Environmental Needs Assessment Checklist

- about the survivor's general community, vocational, and education environments. - addresses the survivor's current and projected environment characteristics, such as setting and the activities expected to take place in that setting, and Social interactions between the survivor and others

Problems of Language/Communication in TBI

- comprehension and production of words, phrases, sentences, and discourse. - spoken and written narrative and discourse, topic selection and maintenance, coherence and cohesion, story grammar, word selection and retrieval. - nonverbal aspects of communication primarily in the form of gestures, facial expressions, and body posture and positioning.

Memory logs

- external memory aids - provide an area for writing and organizing notes about events as they unfold, and events to happen in the future. - survivors write comments about daily events.

Restorative Treatment

- intervention approaches that are focused toward restoring lost or impaired functions. When using these restorative treatments it is good to focus on the individual's orientation, attention, memory, pragmatic behaviors, and executive functioning.

pragmatic interventions for TBI

- making and viewing the video of a survivor interacting with other individuals. A very important note is that the clinician identify linguistic, extralinguistic, and paralinguistic contributors that affect or violate the appropriate pragmatic behaviors. Then, share with the client the effect that those behaviors have with their interpersonal relationships. - generate cueing systems in order to alert the client when he/she is violating any pragmatic standards.

Memory-enhancement techniques

- memory exercises (computer-based or paper-and-pencil) used to assist with recalling large quantities of information. - using mnemonic strategies, such as chunking, quantifying, verbal rehearsal, forming paired associates, and engaging in visual imagery ▪ Chunking-Method for recalling telephone numbers, license plates, or word lists. It involves decreasing the number of pieces of information a person must remember by grouping items together ▪ Quantifying-tallying the number of items on a list and using that number as a cue to recall ▪ Verbal Rehearsal-Repeatedly reciting aloud or to oneself to-be-recalled information. - used in conjunction with other techniques to further facilitate information recall. ▪ Visual Imagery-imagining a familiar object or place and visualizing it connected in some manner with the to-be-remembered information; ▪ First letter mnemonics-acronyms using the first letter of each word ▪ SQ3R: Survey, Question, Read, Recite, Review ▪ Spaced retrieval training-eRelies on the principle of expanded rehearsal, specifically repetitive, errorless practice recalling a specific piece of concrete information over increasingly longer time intervals; this procedure focuses on teaching one piece of information at a time

cueing systems

- to generalize the skills learned, - alerts the client when he/she is violating any pragmatic standards. - transfer the use of this cueing system to anyone familiar - i.e. lightly touch the client's elbow when he or she is not allowing the conversation to be an even exchange with the communication partner so that the other individual is able to contribute to the conversation.

Mechanism of Injury Approach

-approach to evaluating and treating patients with blast-related polytrauma, - the base rate associated with a particular mechanism of injury, as well as medical evaluations by a physiatrist, are used to make assessments and referrals to other specialists in an interdisciplinary team. - leads to early intervention. - more time efficient approach

depression

-consider when devising a treatment plan - its impact on cognition, function, and overall progress. Major Depressive Disorder (MDD) is believed to occur in 33% - 42% of individuals within the first year post-TBI, and in 61% of individuals within the first 7 years post-TBI. - linked to poorer functional social skills, poorer global outcomes, and poorer self-reported quality of life ratings - can be treated with a variety of methods including pharmacological, psychotherapeutic, and cognitive behavior management interventions. Psychotherapy is currently the most recommended form - individuals with TBI have a greater chance of experiencing negative reactions to pharmacological treatments - . SSRIs, or selective serotonin reuptake inhibitors, are considered the primary antidepressants used for individuals with TBI

Brief Test of Head Injury (BTHI)

A screening test that contains more subtests for language, such as reading comprehension and naming, than can be found in the Cognistat. It can be administered at bedside in 20-30 minutes

ADL interventions

Acute Stage: assessment and monitoring of attentional, executive functions and auditory processing skills. Rehabilitation Stage: achieve functional objectives. 1. Traditional Approach to cognitive rehabilitation: ▪ Goal - Restore cognitive functions ▪ Focuses on compensatory strategies if restorative intervention is unsuccessful. ▪ Treatment Modalities and Methods ▪ Cognitive exercises to restore cognitive processes or skills ▪ Cognitive exercises to acquire compensatory cognitive behavior ▪ Decontextualized exercise to eliminate or reduce cognitive impairment. ▪ Uses computers ▪ Clinical setting (ASHA, 2003) 2. Flexible and Contextualized intervention approach: ▪ Goal - help patients with cognitive disabilities achieve functional objectives and participate in chosen activities that are at least temporarily blocked by the impairment. ▪ Following interventions may include: ▪ Body structure/function -oriented interventions (decontextualized retraining exercises for real-world functioning) ▪ Activity/participation interventions (Compensatory strategies & improve performance) ▪ Context-oriented interventions (manipulating the environment) 2. Treatment Options ▪ Peer group training of pragmatic skills ▪ Web-based family problem-solving intervention ▪ Behavioral interventions for behavior disorders after TBI ▪ Social skills intervention for adolescents with TBI ▪ Intervention for memory disorders after TBI ▪ Treatment of discourse deficits following TBI ▪ Teaching compensatory strategies: modeling, direct instruction, and functional practice ▪ The Rivermead Postconcussion Symptoms Questionnaire

Profile of Executive Control System

An observational protocol involving the examiner observing the TBI survivor perform daily tasks, setting up tasks for the client to complete, and interviewing the clients and caregivers about their executive function skills. - suggests several unstructured places to do the observations. - areas of executive functioning addressed: goal selection, planning/sequencing, initiation, execution, time sense, awareness of deficits, and self-monitoring

Neurobehavioral Cognitive Status Examination (NCSE) or Cognistat

Assesses intellectual functioning in five ability areas (i.e. language, construction, memory, calculation, and reasoning/judgment). It takes 20-30 minutes to administer. It may be better suited for younger adults due to relative difficulty compared to other screening tests

Spaced retrieval

Clients who have impaired executive function and attention, which impedes their ability to assess the context, complete tasks while considering multiple variabilities, or complete other higher level tasks.

◦ Phases of TBI Recovery:

Coma - eyes closed Minimal conciousness - eyes open, unresponsive or unintentional Emergence from Minimal Conciousness - eyes open & responsive with intent Rapid Spontaneous Recovery - 6 months Final Spontaneous Recovery - 6 mo - 2 yrs

Memory Interventions

Direct: - Memory logs - Memory-enhancement techniques - Errorles Learning - Spaced retrieval Indirect: - Lists - Electronic devices

Cognitive symptoms of TBI

Executive function ▪ Attention and Concentration

▪ Executive function symptoms of TBI

Frontal lobe damage is highly associated with executive function deficits. Executive function abilities refer to a collection of high-level, interconnected, control processes that allow us to generate, choose, organize, and regulate our goal-directed, adaptive, and non-automatic behaviors." (Murray & Ramage, 2000)

Age and Gender

Gender is not a prognostic indicator Young children have a better prognosis for recovery than adults following a traumatic brain injury due to physiological differences and neuroplasticity.

oral motor mechanism exam

In addition to formal standardized tests used to specifically test cognitive abilities and language, the SLP also should complete an oral motor mechanism exam to assess the muscles that control speech

Dysphagia Management Post-Rehabilitation Stage

Indirect Treatment: 1. Family/caregiver education... ▪ to identify swallowing risks and need for swallowing precautions ▪ supplemental verbal explanations with diagrams and video results from a survivor's swallow study ▪ summaries of research findings ▪ to reinforce the use of modifications 2. Training of family members regarding food and drink preparation

Dysphagia Management Post-Acute Stage

Indirect Treatment: ▪ Diet modification Therapy Direct therapy: 1. Compensatory Postures: ▪ Increases the safety of swallowing food and liquids ▪ Easy to achieve and tolerate ▪ Chin up, chin down, head rotation, head tilt, side lying. 2. Maneuvers: ▪ Requires attention and cognitive processing ▪ Breaks down the process of swallowing into deliberate and voluntary series of movements ▪ Include direct instruction w/ multiple repetitions to increase mastery. ▪ Immediate affect - increases safety ▪ Therapeutic affect - increases motor skills ▪ Supraglottic swallow, Super-supraglottic swallow, effortful swallow, multiple swallows, & Mendelsohn Maneuver. 3. Exercise Treatment ▪ Strengthening, range of motions, and coordination of swallowing musculature ▪ Masako Maneuver ▪ Shaker Exercise ▪ Thermal Tactile Stimulation ▪ Cross-Skill Treatment ▪ Respiratory training programs Ex: Lee Silverman Voice Treatment

Dysphagia Management Acute Stage:

Indirect therapy: Education and counseling family members and caregivers regarding swallowing disorders. ▪ Factors relate to the time of initiating oral feeding and to the length of time to achieve total oral feeding. Direct therapy: ▪ Due to minimally responsive individuals or comatose states, clinicians may need to postpone treatment.

Mechanism of injury

Mechanism of injury extent and location, or how much neural tissue that has been damaged, can also be used as a prognostic indicator.

Palatal Lifts

Palatal Lifts (Stage 1 or 2 of TBI survivors) - Indirect intervention ▪ Used when speakers with dysarthria cannot achieve velopharyngeal closure by voluntarily modifying their speech patterns ▪ Palatal appliance- prosthetic that covers the hard and soft palates; it lifts the soft palate and provides a surface against which the lateral walls of the pharynx contract ▪ Fitting the palatal lift early in recovery of TBI can encourage use of residual speech abilities; may also facilitate vowel production Treatment candidacy: This is used for individuals with dysarthria, and those with severe velopharyngeal dysfunction (abnormal nasal emission) not modified by behavioral treatment approaches Duration: Wear palatal lift 3 - 4 hours at a time Who should conduct the treatment? SLPs; prosthodontists fit the palatal lift

Prognostic Factors of TBI:

Prognosis for recovery following a traumatic brain injury (TBI)= unpredictable - length of impaired consciousness - posttraumatic amnesia - reduction or elimination of primitive oral reflexes appears to be related to the recovery of functional speech. - Age - Mechanism of injury

Mood symptoms of TBI

Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings

Sensory Modality Assessment and Rehabilitation Technique (SMART)

Rating Scale for Determining Consciousness - Used to assess and discriminate the awareness of people in vegetative states, and determine if the survivor is transitioning from a vegetative state to impaired consciousness. Elicited responses to sensory stimuli are categorized into five levels: Level 1 - No Response; Level 2 - Reflexive Response; Level 3 - Withdrawal Response; Level 4 - Localizing Response; and Level 5 - Discrimination Response. The examiner can administer this protocol on a routine basis to identify the initial point when the survivor begins to demonstrate awareness and interaction within the environment. Sensory stimuli include visual, tactile, auditory, olfactory, and gustatory modalities. There is evidence that SMART may be especially sensitive to subtle gains in awareness

JFK Coma Recovery Scale-Revised

Rating Scale for Determining Consciousness - presentation of 24 stimulus items, which make up the six subscales (auditory, visual, motor, oromotor, communication, and arousal functions). -Every item targets a response behavior; the examiner determines if that behavior is present or absent. The items in each subscale correspond to three types of conscious states: vegetative, minimally conscious, and emergence from minimal consciousness.

Coma/Near Coma Scale

Rating Scale for Determining Consciousness -Used to measure subtle clinical changes in people with impaired consciousness. - evaluates the survivor's response to 6 sensory modalities: auditory, visual, olfactory, tactile, pain and vocalization. - Points are assigned according to the number of responses to the stimuli of each of the sensory modalities

Glascow Coma Scale (GSC)

Rating Scale for Determining Consciousness ◦ Levels I-III address behaviors associated with people in comatose, vegetative, and minimally conscious states. ◦ Levels IV-VI address behaviors associated with people who are regaining basic self-regulation, orientation, and memory skills ◦ Levels VII - X address behaviors in individuals with remaining cognitive deficits affecting transition back into social, academic and vocational pursuits - used in medical settings to make behavioral observations. A score of 3-8 indicates a coma or vegetative state, which also indicates severe damage and can be a prognostic factor. A GSC of 9-14 indicates minimal consciousness and a GSC of 15 indicates normal consciousness

The Ranchos Scale or Ranchos Los Amigos Levels of Cognitive Functioning

Rating Scale for Determining Consciousness +subjective impression of the patient's cognitive status. - response to sensory stimulation, - level of agitation and confusion, - deficit awareness, - reliance on others to direct and focus attention, -delay in responding, - need for supervision during functional activities. This scale can be used as a prognostic indicator. A good prognosis would be the patient obtaining a 4-6, meaning that the individual is regaining basic sensory regulation, orientation and memory abilities.

Articulation Interventions- stage 1

Stage 1: No useful speech ▪ Intensive therapy to assist clients with regaining neuromotor control (focus is on physiological building blocks of speech) ▪ Establish consistent subglottal air pressure ▪ Eliminate abnormal respiratory behaviors ▪ Inspiratory checking - technique of controlling airflow through the larynx ▪ Establish voluntary phonation- cue individual to sustain sound production ▪ Establish controlled phonation - pushing and pulling activities - through pushing down on armrests of a chair, pulling against bicycle handlebars. ▪ Postural adjustments - adjust posture depending upon type of dysarthria ▪ Increasing loudness - interventions include behavioral training, and pushing and pulling activities ▪ Early Speech Sound Production ▪ Focus of articulation treatment on the client's production of a # of different vowel and consonant sounds, single words, and short phrases ▪ Production of specific vowel and consonant sounds that are distinguishable from one another ▪ Contrastive drills - Includes CV combinations, and eventually single words

Shaker Exercise

Treatment candidacy - Individuals with a decreased opening of their upper esophageal sphincter -Who conducts the treatment - SLP -Intensity and duration - 3 times per day for 6 weeks

Articulation Interventions- stage 2

Stage 2: Speech Supplemented by AAC Interventions to enhance speech precision ▪ Contrastive production and intelligibility drills ▪ Clinicians provide speakers with information about the adequacy of production and ask them to make changes in motor performance to improve the perceived speech output. ▪ This approach encourages speakers to make the changes they can in the execution of speech movements to compensate for their neuromotor impairments ▪ Adjust speaking rate ▪ Alternate the speaking rate to enhance speech precision - particularly helpful for TBI survivors with an apraxic component Physiological Interventions ▪ Establishing consistent respiration function during speech ▪ Optimize phonation stability Establishing Consistent Respiratory Function for Speech ▪ Stage 1: speakers with TBI regain sufficient respiratory support for consistent phonation and the initial production of a limited number of words ▪ Stage 2: Intervention that attempts to return the speaker to consistently using a target respiratory rate (65% to 35% lung volume). ▪ Intervention may include specific biofeedback, such as a display of lung volume, or behavior instruction to return to proper range of lung volume Optimizing Phonation Function ▪ Survivors of TBI frequently exhibit monotonous speech ▪ Interventions: Coaching through direct instruction- e.g. speak with less effort, speak with more effort, etc), and feedback from a sound level meter or through the monitoring of intra-oral air pressure during speech ▪ Effortful closure techniques include pushing and pulling; may be appropriate for those with laryngeal flaccidity Palatal Lifts (Stage 1 or 2 of TBI survivors) - Indirect intervention ▪ Used when speakers with dysarthria cannot achieve velopharyngeal closure by voluntarily modifying their speech patterns

Articulation Interventions- stage 3

Stage 3: Speech Intelligibility Reduced in Some Situations Intervention goals are the following: 1.) Learn to structure communication situations so both listeners and speakers can function optimally 2.) Improve intelligibility and naturalness of prosodic elements of speech 3.) Optimize speech breathing patterns, voice quality, and velopharyngeal and articulatory function ▪ Respiration Interventions ▪ Retrain speakers to take breaths at the appropriate point in the utterance using: ▪ A.) Role-playing conversational exchanges (Direct intervention) ▪ B.) Review audiotapes, or DVDs of training activities to provide feedback regarding appropriate breathing patterns (Indirect intervention) ▪ C.) Lee Silverman Voice Treatment (LSVT) - (Direct intervention) ▪ Laryngeal Intervention ▪ Traditional voice therapy ▪ Velopharyngeal interventions ▪ Continuous positive airway pressure (CPAP) - (Direct intervention) ▪ Speaking rate control - can result in increased intelligibility (Direct intervention)

Articulation Interventions- stage 4

Stage 4: Obvious Speech Disorder with Intelligible Speech Interventions to enhance overall naturalness of speech: (Direct interventions) ▪ Intonation patterning ▪ Breath-pause patterns ▪ Stress patterning

Why informal assessment is prefferred

Standardized assessments typically do not distinguish the specific cognitive-linguistic deficits experienced by TBI survivors in real life situations, as these assessments typically take place in a controlled environment that are free of distractions. TBI survivors tend to perform well on language related tasks and in tasks that are guided by someone else, so small communication samples do not adequately provide insight into issues with executive functioning, attention, and memory

designing a plan for reintegration

The ultimate goal is to help them return to school or work with the ability to function, and communicate, successfully within those environments. - students, focus on the importance of their education rather than on the injury - workers, severity of the brain injury plays a large role in what kind of work following the injury. encourage their clients to utilize their loved ones for support in identifying their goals for the future and working towards them. Materials have been developed to help individuals with TBI map out their plans for the future in regards to their dream job (ACT). - includes the determination of the individual's readiness to work and this should be assessed regularly, even after the individual has been matched to a job There are various accommodation strategies that an individual with TBI can use in order to be successful in the workplace. Service providers, such as vocational rehabilitation counselors, are responsible for helping identify and implement these accommodations

determine severity of the TBI

To determine severity of the TBI, the duration of coma, depth of coma, and duration of posttraumatic amnesia (PTA) are used.

Diet modifications

Treatment candidacy - Individuals who have a tendency to aspirate -Who conducts the treatment- Dieticians confirms the type of diet (puree, mechanical soft, regular), and SLPs provide this type of bolus consistency to the TBI survivor

Thermal-Tactile Stimulation

Treatment candidacy - Individuals with dysphagia who are experiencing a delayed onset of the swallow reflex -Who conducts the treatment - SLPs -Intensity and duration- Several short (10 to 15 minute sessions, several times a day

CLQT (Cognitive Linguistic Quick Test)

an assessment "for adults (18 to 89) with a known or suspected neurological dysfunction (e.g., stroke, TBI, or dementia)" measures strengths and weaknesses through 10 tasks in cognitive domains, including attention, memory, executive functions, language, and visuospatial skills - allows clinicians to make qualitative observations, including "perseveration, response delay, self-correct, "set" problems, cooperation, need for prompts, no response, unintelligibility, or other observations" - quick assessment for further evaluation in the areas/cognitive domains of concern

Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) formal cognitive assessment

assesses cognitive and linguistic functions, provides a severity level and tracks progress of recovery in brain-injured individuals. The SCATBI measures many different functions including auditory comprehension, memory, orientation, reasoning, and word finding.

The Ross Information Processing Assessment - Second Edition (RIPA-2)

assesses cognitive-linguistic deficits, by determining severity levels for each of the following skill areas: immediate memory, recent memory, temporal orientation, temporal orientation, spatial orientation, orientation to environment, recall of general information, problem solving and abstract reasoning, organization, auditory processing and retention *can be used to assist in creating rehabilitation goals and objectives.

Behavior symptoms of TBI

behaviors may include aggression and violence, impulsivity, disinhibition, "acting out", noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired self-awareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. ▪ "Individuals with brain injuries may lack self-control and self-awareness, and as a result they may behave inappropriately or impulsively (without thinking it through) in social situations. ▪ They may deny they have cognitive problems, even if these are obvious to others. ▪ They may say hurtful or insensitive things, act out of place, or behave in inconsiderate ways. ▪ They may lack awareness of social boundaries and others' feelings, such as being too personal with people they don't know well or not realizing when they have made someone uncomfortable." (Neumann & Lequerica).

General Behavioral Observation Form

characterize an individual's abilities in the areas of attention, executive functions/metacognition, processing and response speed, emotional control, drive and motivation, and memory. There are subskills for each category (ex. memory subtests include repetition needed, reauditorizations and confabulations)

AAC intervention

consider the following ◦ Physical, visual, motor speech, cognitive, and/or language impairments ◦ The individual's phase of recovery ◦ The rehabilitation setting ▪ Acute ▪ Post-acute ▪ Post-rehabilitation ▪ Acute Rehabilitation and AAC ▪ Associated with early phase of recovery ▪ Most individuals are not able to communicate via natural speech ▪ Other impairment may be confounding speech recovery ▪ Intervention involves dynamic assessment Identify response modalities (e.g. gestures and/or facial movements) Consider physical limitations and the types of stimuli that elicit responses (e.g. music, pictures) ▪ Successful implementation requires: 1. Consistent responses to stimuli 2. Physical response modality is established 3. Identification of consistent yes/no response modalities ▪ Goal of AAC intervention: Shaping response modalities ▪ AAC options Low-tech examples Communication Board or Book - requires functional use of their hands. Mid-tech examples (speech-generating devices; SGDs) -BigMack - requires limbs and/or head as a response modality. -Macaw 5 -Keyboard devices -Twin Talk - requires functional use of their hands. High-tech examples (SGDs with dynamic display) -Dynavox Vmax -iPad applications -Tobii I12 AAC Accessories Laser pointer - uses eye/head movement. Latch-timer - uses gross motor movement of their hands and/or arms. ▪ Post-Acute Rehabilitation and AAC Associated with middle and late phases of recovery Individuals may evidence the ability to use natural speech Persistent deficits may require long-term use of AAC ACC device trials are ongoing and extensive Insurance and funding options Carryover of AAC trials and intervention to new settings/caregivers Provide caregiver training on operation of the device and AAC strategies Client's support system Device customization Goal of AAC intervention: Identification of a device for long-term use and acquisition of AAC strategies in order to achieve functional communication The SLP should encourage multi-modal communication and teach the individual to communicate via several modalities, AAC systems, and strategies. ▪ Post-Rehabilitation and AAC ▪ Associated with the late phase of recovery and discharge from treatment ▪ The SLP needs to provide follow up services due to changing needs, abilities (e.g. spontaneous speech recovery), life circumstances (e.g. transitions in living situations), and financial support ▪ Important to identify, train, and maintain communication advocate(s) for the individual with TBI to ensure continuous AAC support. ▪ Goal of AAC intervention: Meeting current and future communication needs while keeping functional outcomes in mind. ▪ Important factors to consider: ▪ Development and maintenance of social networks ▪ The individual's willingness to use AAC ▪ The communication partner's attitude towards AAC i.e. use of contextualized interventions, which involve the following: -Contextualized Paradigm Goal: To assist the client in achieving functional objectives in real-world settings using the WHO (2001) framework. ▪ Environmental modifications: Training communication partners on scaffolding techniques Mediated interactions between the client and their communication partners (e.g. employer, friend, family member) ▪ Task modifications: Target cognitive-communication skills in the context of the client's typical routines Use scaffolding technique (e.g. fading) during cognitive exercises Follow a treatment hierarchy: intra-cognitive hierarchies, generalization hierarchies, and the body structure/function-to-activity/participation-to context hierarchy

depth of coma

depth of coma is measured using the Glasgow Coma Scale (GCS), and the "PTA includes the period of coma and extends until the patient's memory for ongoing events becomes reliable, consistent, and accurate" (Sohlberg & Mateer, 2001).

An important acute-rehabilitation goal

determining whether a survivor exhibits aphasia in addition to a cognitive-communication deficit." TBI patients display difficulties with communication due to cognitive impairments; such as, deficits in word finding, attention, memory, and more.

duration of coma

duration of coma after TBI appears to have a "direct and linear relationship" with recovery severe=a duration of over 6 hours moderate=less than 6 hours mild=20 minutes or less

Checklist of Listening Behaviors

five point scale from "almost never" to "always", respondents rate the frequency of certain listening behaviors observed in conversation. Items include maintaining proper level of arousal, maintaining eye gaze, asking for clarification when necessary, inhibiting thoughts and refraining from interrupting

Interdisciplinary team is vital

importance of using a interdisciplinary team during the screening process prior to receiving treatment for a blast-related injury.

spontaneous recovery

in general, the most rapid period of recovery following moderate to severe injury occurs during the first six months after injury, with slower yet ongoing recovery up to 2 years following injury

The goal of dysphagia treatment

is to decrease negative symptoms and restore safe oral intake. Many common dysphagia interventions require sufficient cognitive skills to follow commands and learn new behaviors. Selecting appropriate strategies and techniques will depend on the patients' cognitive capabilities.

assessing brain injuries

know the nature, extent, and location of the brain damage in order to predict how cognition, language, communication, etc. are impacted. Knowing that an injury is open or closed only reveals the nature of the damage and therefore cognitive, linguistic, and behavioral factors cannot be predicted.

Language (e.g., word finding, understanding) symptoms of TBI

knowledge and complexity, overabundance of language production ▪ Understanding: After brain injury, a person's ability to process and understand information often slows down, resulting in the following problems: ▪ Taking longer to grasp what others are saying. ▪ Taking more time to understand and follow directions. ▪ Having trouble following television shows, movies, etc. ▪ Taking longer to read and understand written information including books, newspapers or magazines. ▪ Being slower to react. This is especially important for driving, which may become unsafe if the person cannot react fast enough to stop signs, traffic lights or other warning signs. Individuals with TBI should not drive until their visual skills and reaction time have been tested by a specialist. ▪ Being slower to carry out physical tasks, including routine activities like getting dressed or cooking." (Neumann & Lequerica)

The Brief Test of Head Injury (BTHI)

measures cognitive, linguistic and communicative abilities of individuals with head injuries. This assessment tool can be used as a baseline for tracking recovery. Because it is brief and efficient (taking 30 minutes to administer and 10 minutes to score), it is an excellent assessment for post-coma patients. Areas that are measured include orientation and attention, following commands linguistic orientation, reading comprehension, naming, memory, and visual-spatial skills

Closed Head Injury (CHI)

occur as a result of a brain injury from an external impact. This damage tends to be diffuse. occurs when there is a force on the head but it does not penetrate the skull; rather, it results in injury to the brain tissue. This type of injury may result from a fall or motor vehicle crash just to name a few. tend to result in more severe cases

focal injury (brain damage)

occurs when damage is confined to a specific part of the brain. Symptoms with focal head injuries are dependent to the site of damage. -affecting more areas of the brain -may or may not occur with diffuse brain damage

Open Head Injury (OHI)

occurs when there is a force on the head that penetrates the skull results from a "traumatic event that causes an opening in the skull, such that the underlying brain is exposed to the external environment largely focal in damage and may result from bullet wounds, stab wounds, and motor vehicle or occupation accidents (nails and screw drivers). disorders affecting cognition, language, and behavior resulting from an open head injury will be more "pure" since the damage is localized to a specific area (e.g., aphasia, apraxia). However, this will not always be the case because every brain injury case is different.

TBI intervention

provide strategies that facilitate the client to organize his/her discourse, minimize tangential speech and topic shading, select appropriate topics of conversation, express facial expressions and gestures, maintain eye-to face gaze during conversation, and attend to and interpret verbal and nonverbal behaviors of communication partners.

Galveston Orientation and Amnesia Test (GOAT)

quick test that can be administered daily. Score of 78 or more on three consecutive occasions is considered to indicate that patient is out of post-traumatic amnesia (PTA)

Blasted TBI

refers to a direct injury or blow to the skull. injuries occurs as a direct result of blast wave-induced changes in atmospheric pressure (primary blast injury), from objects put in motion by the blast hitting people (secondary blast injury), and by people being forcefully put in motion by the blast (tertiary blast injury)."

◦ What is the mechanism of: OHI; CHI; Blasted TBI?

refers to the type or physiological impact of head injury

Diffuse injury (brain damage)

results in more diverse overall deficits in attention, emotions, learning, memory, thought processes, and abstract thinking. Individuals with diffuse brain damage typically have intact language rule systems but have cognitive challenges that cause them to be inefficient and ineffective -tend to result in more severe cases

risk factors for TBI

risk factors for TBI include substance abuse and preexisting medical conditions

duration of posttraumatic amnesia (PTA)

the duration of PTA been found to correlate well with residual physical and cognitive impairments

Functional Assessment Measure (FIM+FAM)

to assess the extent to which a person's disabilities affect performance of self-care activities.

Post-Rehabilitation

used to address lingering cognitive and cognitive-communication challenges among TBI survivors. This rehabilitation helps to reintegrate the individual into their social, educational, and vocational settings.

Acute Care Rehabilitation

used when survivors are beginning to demonstrate the reemergence of initial communication attempts, whether they are verbal or nonverbal attempts.

Communication- (e.g., pragmatics) symptoms of TBI

▪ "Communication problems can cause persons with TBI to have difficulty understanding and expressing information in some of the following ways: ▪ Difficulty thinking of the right word. ▪ Trouble starting or following conversations or understanding what others say. ▪ Rambling or getting off topic easily. ▪ Difficulty with more complex language skills, such as expressing thoughts in an organized manner. ▪ Trouble communicating thoughts and feelings using facial expressions, tone of voice and body language (non-verbal communication). ▪ Having problems reading others' emotions and not responding appropriately to another person's feelings or to the social situation. ▪ Misunderstanding jokes or sarcasm." (Neumann & Lequerica).

assessments commonly used for patients with aphasia on TBI patients

▪ ABCD ▪ CLQT (Cognitive Linguistic Quick Test)

Language/Communication Interventions

▪ Acute Care Rehabilitation ▪ Restorative Treatment ▪ Post-Rehabilitation ▪ Errorless Learning ▪ Positive everyday routines

Direct treatment of executive functioning skills

▪ Compensatory strategies for memory (memory logs, daily planners) (ASHA & Hux, 2011) ▪ Impairment specific strategies i.e. computer memory games ▪ Imposing self-monitoring techniques ▪ Teaching new organizational methods ▪ Neurologic Music Therapy (NMT) ▪ Errorless Learning ▪ Positive everyday routines

Extralinguistic Contributors

▪ Eye Gaze ▪ Affect ▪ Gestures

Paralinguistic Contributors

▪ Tone ▪ Intonation ▪ Rhythm ▪ Prosody

Indirect treatment of executive functioning skills

▪ Treatment in a contextualized paradigm ▪ Electronic aids-such as pre programmed alarms, daily goal sheets ▪ Counseling family members

Microlinguistic Processing

▪ Verbal production - Sometimes oral communication from TBI can be excessively verbal, inefficient, and/or include logorrhea ▪ Word selection and retrieval - among the most commonly observed and persistent challenges in TBI ▪ Number of words produced ▪ Syntactic and morphologic proficiency ▪ Number of ideas or propositions in single sentences *Microlinguistic deficits are more obvious in individuals with aphasia than in those with cognitive-linguistic disorders, but survivors of TBI may still struggle with number of words produced, efficiency of word retrieval and number of multiple propositions within single utterances

ABCD

▪ can be used for individuals with TBI in an informative and subjective manner to supplement other assessment measures. ▪ This assessment is useful for differential diagnoses associated with TBI - targets Linguistic Expression, Linguistic Comprehension, and Visuospatial Construction. The skills consistent with those found in TBI. The linguistic expression subtest contains tasks that target word finding difficulties; such as, object description, generative naming, confrontation naming, and concept definition. The linguistic comprehension subtest contains tasks that can be used to target deficits in processing information; such as, following commands, comparative questions, repetition, and reading comprehension at the word and sentence level. The Visuospatial Construction subtest contains tasks that target deficits in orientation; such as, generative drawing and figure copying. ▪ TBI Norms - Individuals with TBI were not included

- Implementing positive everyday routines

▪ help survivors be successful performing tasks promoting independence ▪ occur "within the context of meaningful everyday activities, relevant everyday people in the person's life, and facilitate the individual's acquisition and internalization of strategies and other behaviors". ▪ provide antecedent supports , meaning assistance that occurs prior to and promote elicitation of the desired behavior.

Errorless learning

◦ Teaching approach found to be effective with severe cognitive and memory problems who are trying to master certain types of learning tasks. - involves the elimination of errors through prompting and the support of correct responses. ◦ Client is provided with correct responses from the beginning and are then instructed to repeat, read, write, or reinforce it in some other way to strengthen the response. this allows inadvertent strengthening of an incorrect response. ◦ To eliminate errors during learning tasks: ▪ perform task analysis to break down a complex behavior into small, discrete steps ▪ provide a model of correct responding before asking the client to perform the task. ▪ encourage client to be strategic in avoiding guessing by asking for assistance when experiencing uncertainty. ▪ using forward-chaining or backward chaining in order to fade prompts.

The following standardized tests demonstrated adequate performance across the majority of the reliability and validity criteria:

◦ The American Speech-Language Hearing Association Functional Assessment of Communication Skills in Adults ◦ Behavior Rating Inventory of Executive Function ◦ Communication Activities of Daily Living, 2nd Edition ◦ Functional Independence Measure ◦ Repeatable Battery for the Assessment of Neuropsychological Status ◦ Test of Language Competence-Extended ◦ Western Aphasia Battery

Macrolinguistic Processing

◦ Topic selection and maintenance ◦ Global and local coherence ◦ Intersential cohesion ◦ Story Grammar ◦ Gist comprehension