3/23/2017 ASSESSMENT AND TREATMENT NEEDS OF THE INDIVIDUAL WITH A TRAUMATIC BRAIN INJURY: A SPEECH-LANGUAGE PATHOLOGIST S PERSPECTIVE

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1 ASSESSMENT AND TREATMENT NEEDS OF THE INDIVIDUAL WITH A TRAUMATIC BRAIN INJURY: A SPEECH-LANGUAGE PATHOLOGIST S PERSPECTIVE MONICA STRAUSS HOUGH, PH.D, CCC/SLP CHAIRPERSON AND PROFESSOR COMMUNICATION SCIENCES & DISORDERS FLORIDA INTERNATIONAL UNIVERSITY COGNITIVE/COMMUNICATION PROFILE IN TRAUMATIC BRAIN INJURY Traumatic brain injury (TBI): insult to brain produced by external forces; projectiles striking the head or the head is moving and suddenly strikes a stationary object. Temporary or permanent physical, cognitive, emotional, and behavioral impairments. SPEECH-LANGUAGE PATHOLOGIST S PERSPECTIVE I COMMUNICATION AND COGNITIVE PROFILE A. LANGUAGE AND SPEECH DEFICITS B. COGNITIVE-COMMUNICATIVE DEFICIT PROFILES C. SPECIFIC PROCESSING IMPAIRMENTS MEMORY ATTENTION EXECUTIVE FUNCTIONING II ASSESSMENT A. PURPOSE OF ASSESSMENT B. NATURE OF ASSESSMENT: Quantifying and Qualifying Deficits C. INTERPRETING ASSESSMENT DATA III TREATMENT A. BASIC TREATMENT PERSPECTIVE B. TREATMENT EMPHASIS C. ROLE OF GROUP THERAPY 1

2 LANGUAGE AND COMMUNICATION SKILLS IN TBI Language and cognitive-communication problems information processing deficits generalized cognitive deficits neuro-physiological deficits typical of diffuse lesions. Also, linguistic and/or speech problems, often result of discrete focal lesions. LANGUAGE IMPAIRMENTS IN TBI Often result of discrete lesions at cortical level Specific language deficits: reduced word fluency (considered most significant predictor of linguistic severity); retrieval, auditory comprehension, reading and writing May somewhat resemble Wernicke's aphasia in regard to their language impairment Specific linguistic deficits can sometimes be masked by severe general cognitive deficits. LANGUAGE IMPAIRMENTS IN TBI Linguistic problems may be associated with more diffuse brain damage pragmatic and discourse deficits Pragmatic and discourse production and comprehension problems often product of: attention, memory, and/or executive function deficits rather than a disordered linguistic system. 2

3 LANGUAGE IMPAIRMENTS IN TBI Pragmatic deficits: poor topic management-- excessive or infrequent topic initiation and inappropriate topic choices. Decreased presentation of information in discourse LANGUAGE IMPAIRMENTS IN TBI Types of linguistic cognitive-communicative problems dependent upon: location and extent of neural structures and pathways damaged by head injury what other cognitive abilities have been compromised. Damage to orbito-frontal regions: highly disinhibited; language output and input abilities reflect this disinhibition However, damage to dorso-lateral frontal regions and reticular activating system (RAS) involvement: apathetic with impaired initiation. LANGUAGE IMPAIRMENTS IN TBI Direct relationship between pragmatics and successful social interactions Thus, appropriate management of pragmatic and discourse problems is critical to reintegration in environment 3

4 SPEECH IMPAIRMENTS Usually result of brainstem lesions. Articulation problems, typically dysarthria (various types) Fluency problems with abnormally rapid rates of speaking Voice problems: vocal fold irritation (due to intubation) more severe problems: vocal fold paralysis. COGNITIVE DEFICITS: DIFFUSE LESIONS THREE PIVOTAL PROFILES: Information processing deficits: affect individual's ability to perceive, discriminate, organize, recall, and solve problems General cognitive deficits: result in an individual's inability to deal with cognitive constructs. Neurophysiological disorders: characterized by profound difficulties with attention and recall NEUROPHYSICAL DEFICIT PROFILE Behavioral deficits resulting from attentional difficulties include: Perseveration, disinhibition, distractability, Impulsivity, stimulus boundedness: individual responds to salient property of stimulus but does not remain oriented to task. 4

5 SPECIFIC COGNITIVE IMPAIRMENTS: MEMORY Certain brain regions especially vulnerable in head trauma: frontal lobes, anterior portions of temporal lobes Memory deficits are usually permanent of varying degrees. Problems completing everyday activities; caregiver burden. WORKING MEMORY IMPAIRMENTS Working memory (WM) impairments particularly vulnerable even in mild TBI. WM deficits strongly associated with language impairments including poor auditory comprehension and discourse production problems LONG TERM MEMORY (LTM) IMPAIRMENTS All aspects of LTM may be negatively affected; most frequently problems with episodic memory Amnesias can occur and extend over minutes, hours, days, weeks, months. 5

6 LTM: RETROGRADE AMNESIA Loss of recall of events preceding injury; may be continuous or interrupted Over time, shrinkage of this type of amnesia However: typically never able to recall circumstances of accident sudden onset of brain damage interfered with encoding events occurring immediately prior to and during accident. LTM: ANTEROGRADE OR POST TRAUMATIC AMNESIA (PTA) Loss of recall of events following injury. Person has difficulty storing and retrieving new long-term memories or more generally any new information Inadequate use of deliberate encoding strategies and retrieval strategies ATTENTIONAL IMPAIRMENTS Important to quantify and qualify attention problems; contribute to other cognitive deficits and communication problems. Most patients are inappropriate candidates for formal assessment or direct treatment in early phases of recovery 6

7 ATTENTIONAL IMPAIRMENTS Patients lack fundamental attentional skills necessary to: attend to the clinician, process task stimuli, plan and carry out task responses. Attention problems most apparent when patients are still in an acute stage of recovery (post traumatic amnesia/anterograde amnesia) Most attention functions (sustained, selective, alternating, divided) severely compromised. ATTENTIONAL IMPAIRMENTS Patients emerging from post traumatic amnesia (PTA): basic attention functions deficits (attention orienting) tend to resolve impairment of more complex attention skills persist. Patients in more chronic stage of recovery (including mild injuries) demonstrate relatively intact attention functioning during simple or more routine daily activities HOWEVER: continue to report/display persisting attention problems with cognitively demanding tasks or when exposed to highly distracting environments. EXECUTIVE FUNCTIONING As frontal lobe damage is frequent consequence of TBI, executive function deficits are pervasive disinhibition, concrete and/or inflexible problem solving and reasoning, poor planning Problems due to impairments in executive functions themselves or to deficits in other cognitive domains (attention) that support executive functioning 7

8 EXECUTIVE FUNCTIONING Deficits particularly influential as negative outcome predictors include: unawareness or limited awareness of deficits cognitive inflexibility. PURPOSE OF ASSESSMENT: ACUTE PATIENT Early phases of recovery: behavioral symptomatology fluctuates May not be able to respond appropriately to standardized tests. Diagnostic impressions may be invalidated in a matter of minutes, hours, or days. PURPOSE OF ASSESSMENT Can include administration of: standardized test instruments use of informal but structured tasks aimed at assessing general cognitive processes Categorization/scaling of behavioral responses to purposefully presented and manipulated stimuli (then use of rating scale: Glasgow Coma Scale, Levels of Cognitive Functioning Ranchos Los Amigos Scale observation of spontaneous responses to typically occurring environmental stimuli. 8

9 NATURE OF ASSESSMENT An adequate test battery should include: sensitivity to verbal/nonverbal performance in confusion graded contrasts between highly structured and open-ended tasks means to tap specific cognitive processes. NATURE OF ASSESSMENT ASSESS LEVEL OF SKILLS: Information Processing and Cognitive Process approach Examination of: Arousal and alerting: Perception and low level attention, Discrimination: ability to differentiate 2 or more stimuli Orientation: rehearsal of basic biographical information NATURE OF ASSESSMENT Examination of: Organization skills: involves categorization, closure, sequencing Memory: short-term memory, working memory, long-term memory Look at number of items recalled, type of stimuli, mode of presentation, and strategies used by patient Higher level thought/abstract processes: convergent thinking, deductive reasoning, inductive reasoning, divergent thinking, multi-process reasoning 9

10 INTERPRETING ASSESSMENT DATA 1) Primary causal factors contributing to behavioral performance breakdown. 2) Effect of each primary factor on receptive, integrative, expressive capacities. 3) Secondary factors affecting performance breakdown 4) Level of cognitive functioning. 5) Relationship and overall effect of primary and secondary factors on functional performance. 6) How can assessment information be used to stabilize, then improve quality of behavior BASIC TREATMENT PERSPECTIVE Cognitive rehabilitation involves: stimulating impaired cognitive function incorporating training of compensatory strategies practice with stimuli and tasks encountered in patients daily routines. BASIC TREATMENT PERSPECTIVE what task requires relative to receptive/expressive abilities; sensory involvement of patient; skills required in performing task. nature of tasks: verbal or nonverbal; social or nonsocial contribution of task 10

11 TREATMENT EMPHASIS: ATTENTION Secondary focus of every task: attention is needed for patients to participate in therapy. Intensive and repetitive practice at completing task sets Progress on simpler tasks that target less complex functions (sustained attention); then more complex attention functions/tasks are introduced. Teach strategies to manage/monitor attention. Incorporate functional attention tasks that resemble patients everyday communication/cognitive activities GOAL: maximize generalization of retrained attention skills to everyday functioning. TREATMENT EMPHASIS: RETRIEVAL/MEMORY PROSPECTIVE MEMORY PROCESS TRAINING (PROMPT): Patients instructed to complete task after a set time interval, manipulating length of delay, task difficulty, presence/absence of distracter during delay, presence/absence of prompts. SPACED RETRIEVAL: Related to PROMPT; patients practice recalling information/use strategy over progressively longer time intervals, with cues; shaping behavior over time. ERRORLESS LEARNING: Based upon implicit learning mechanisms: If patients prevented from making errors during initial learning, they should acquire new information/skill more quickly; patient not allowed to make errors-- cues provided until patient certain they can answer accurately. TREATMENT EMPHASIS: EXECUTIVE FUNCTION Environmental Adaptation Approaches: Modification of environment by reducing task demands Awareness Training approaches: Targets patients understanding of current strengths/weaknesses and ability to monitor performance online Goal Setting and Problem Solving: Teaching task-specific routines by analyzing and dividing the behavior/routine into a series of simple steps, Goal Management: train patients to adopt a strategy that helps complete complex behaviors. 11

12 ROLE OF GROUP THERAPY Group treatment: introduce as soon as patient can handle this type of interaction. Interdisciplinary approach: group leadership can be rotated task can be devised to accomplish different goals in various disciplines Type of group: cognitive level of group purpose or goals of group specific tasks to be introduced group leaders THANK YOU FOR LISTENING QUESTIONS??? 12