This chapter provides an overview of the role of the speech-language pathologist (SLP) in the management of individuals with traumatic brain injury (TBI). Although the discussion includes specific reference to cognitive rehabilitation, it is not intended to be a comprehensive presentation of that topic. Such an undertaking is beyond the scope of a single chapter. The reader is referred to sources on cognitive rehabilitation that cover the topic in greater depth (Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury, ¹ Ponsford et al, ² Sohlberg and Mateer, ³ Sohlberg and Turkstra ⁴). Rather, the emphasis in this chapter is on an overview of intervention practices for individuals with TBI used by SLPs in medical settings.

The chapter reviews the neuropathology and incidence of TBI, and describes the rehabilitation continuum in which individuals with TBI are assessed and treated. The practice patterns utilized in each setting are discussed and illustrated with case examples.

7.2 Definitions and Mode of Injury

TBI may be thought of as a subset of acquired brain injury (ABI), which includes not only TBI but stroke, hypoxic hypotensive injury, infectious disorders like encephalitis, and brain tumors. ⁵ This chapter focuses specifically on the management of TBI; however, many of the interventions described are applicable to other categories of ABI as well. TBI may be classified into two broad categories—open and closed—based on whether or not the meninges remain intact. Open head injuries occur when the scalp, skull, and meninges are penetrated, as in a gunshot wound. Closed head injuries typically result from mechanical forces. For example, if a moving head comes in contact with a stationary surface (e.g., automobile dashboard or windshield) or if the head is struck by a moving object (e.g., with a baseball bat or pipe), resulting in skull fractures and tissue damage to the underlying brain surface. Another common mode of injury is acceleration-deceleration, in which the moving head suddenly stops but the brain continues to move in the original direction and then suddenly reverses its path. Once the brain collides with the inside surface of the skull, areas of contusion result. The point of initial impact is referred to as coup, and when the brain rebounds in the opposite direction and impacts another surface of the skull, contrecoup. Injury may also occur when the brain is scraped across the rough inner surfaces of the skull, particularly at the base of the skull. The orbital and lateral surfaces of the frontal and temporal lobes are vulnerable to this type of injury. ^{3,​ 6} These contusions and abrasions result in focal lesions. A different type of brain damage that often occurs during the acceleration-deceleration process is microscopic, that is, at the level of the brain cell axons. The jerking and/or twisting motion of the brain during acceleration and deceleration may result in axonal stretching, shearing, and tearing. This type of injury results in widespread damage termed diffuse axonal injury (DAI). This damage results in disrupted neuronal communication among various brain regions. ³ TBI is characterized not only by the primary damage (i.e., focal and diffuse lesions) just described, but also by a variety of secondary factors, such as infection, oxygen deprivation, brain swelling, and elevation of intracranial pressure.

As a result of the recent conflicts in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) a different mechanism of damage resulting in TBI has received a great deal of attention, that is, combat-related blast injury. Exposure to blast may result in injury from one or more of four mechanisms: The primary mechanism results from rapid pressure changes from the blast wave in organs with air-fluid interfaces. ⁷ Secondary injury occurs when debris, set in motion by the blast, strikes the body, resulting in focal damage. The third mode is when the body is thrown against a surface, which causes injury. Finally, the fourth mechanism includes other processes, such as inhalation of toxic agents or radiation. As reported by Meyer et al, ⁸ blast injury may co-occur with either blunt or penetrating trauma. However, combat-related TBI is typically mild and associated with concussion.

7.3 Incidence

There are approximately 500,000 new cases of TBI each year in the United States, or roughly 200 cases per 100,000 persons. Adolescents and young adults ages 15 to 24 have the highest incidence of TBI, typically associated with motor vehicle crashes. Older adults over the age of 65 and children under the age of 5 have the next highest incidence of TBI, most commonly resulting from falls. Males are twice as likely to experience a TBI as females, and individuals with a previous TBI are three times more likely to suffer a subsequent TBI. ⁹ Since military monitoring of combat-related TBI in OIF and OEF was initiated in 2009, over 200,000 service members have been diagnosed with TBI, approximately 80% of which were categorized as mild. ⁸

7.4 Severity of Injury

The seriousness of a TBI is determined by a variety of factors, including the distribution of the injury (i.e., focal or multifocal lesions, and/or DAI), severity (i.e., size, location, and depth of lesions), and type of underlying pathology. There are several indices of TBI severity ( ▶ Table 7.1). Some of the more commonly applied measures are the Glasgow Coma Scale (GCS), ¹⁰ duration of coma, and length of posttraumatic amnesia ( ▶ Table 7.2). The GCS assesses severity of injury by rating the degree of eye opening, the best verbal response, and the best motor response. Lower GCS scores are associated with poorer outcomes. Coma is a prolonged period of unconsciousness, and in most instances a longer duration of coma is associated with greater severity of injury (see next section for more information pertaining to coma). Posttraumatic amnesia (PTA) refers to the length of time during which memories are not stored and thus new learning cannot occur. Severity of PTA is often measured by the Galveston Orientation and Amnesia Test (GOAT) ( ▶ Table 7.3). ¹¹

7.5 Cognitive and Communicative Sequelae of Traumatic Brain Injury

Traumatic brain injury results in a diverse, idiosyncratic constellation of cognitive-communicative, physical, and psychosocial deficits. The most common sequela of TBI is a reduced capacity to pursue premorbid interests and daily activities at a comparable functional level. Such difficulties exist along a continuum ranging from the need for additional time to complete tasks to total dependence on others for all basic needs. It has been estimated that 75% of all cases of TBI can be characterized as mild (defined in ▶ Table 7.4). The most characteristic features of TBI are the resulting cognitive disturbances that are often present after the injury. Multiple processes may be disrupted, including attention, memory, organization, reasoning, executive functioning, communication, and social skills. Recovery after TBI progresses through a series of predictable stages ( ▶ Table 7.5). However, it is important to emphasize that recovery is specific to individual circumstances and therefore may vary in both extent and rate. Pre-injury abilities, personality of the individual, and severity of the injury all influence recovery. What follows is a brief review of common sequelae that SLPs are confronted with as they manage individuals with TBI.

7.5.1 Coma

Coma is the term applied to the condition in which a patient displays minimal, if any, purposeful response to the external environment. ¹² Coma is relatively common and is believed to result from damage to the central portions of the brainstem. In deep coma, a patient may demonstrate no discernible behavioral responses to touch, pain, sound, or movement, although autonomic physiologic responses (those not under voluntary control), such as blood pressure or heart rate, sometimes change with sensory stimulation. In lighter stages of coma, the patient may respond to external stimuli but responses may be generalized, for example, whole body movements or nonspecific motor responses. An intense level of stimulation may be required to elicit such responses. Duration of coma has some prognostic implications in terms of long-term recovery. However, the predictive power is not perfect, inasmuch as some individuals who undergo lengthy comas may demonstrate good recovery, and other individuals who experience no loss of consciousness may be left with extensive physical and cognitive deficits. The term persistent vegetative state (PVS) is applied to those individuals who survive but never regain any degree of consciousness in the sense of higher cortical function; they neither speak nor follow commands, but do regain the alerting mechanism. ^{12,​ 13,​ 14,​ 15}

The American Academy of Neurology (AAN) ¹⁶ recommends the use of the term PVS after an individual has been in that state for one month. The Aspen Neurobehavioral Workgroup ¹⁷ suggested use of the term PVS be discontinued and that the diagnosis of vegetative state be accompanied by a description of the injury as well as time since onset, as both factors provide prognostic information. Current AAN practice guidelines recommend using the term PVS 3 months after nontraumatic brain injury, and 12 months after TBI. The term suggests that additional recovery of consciousness after these time points is improbable. ¹⁸ Minimally conscious state (MCS) is also a condition of altered consciousness in which there is minimal but definitive evidence of self- or environmental awareness. ¹⁹ MCS generally represents a transitional stage reflecting an improvement in consciousness or, as in the case of neurodegenerative disease, progressive decline. Diagnosis of MCS is based on consistent evidence of one or more of the following behaviors: following simple commands, intelligible verbalization, recognizable yes/no responses (verbal or gestural may or may not be accurate), and movements or emotional responses to relevant environmental stimuli not attributable to reflexive activity. ¹⁸

7.5.2 Cognitive Disturbances

Several areas of cognition may be disrupted after TBI, including orientation, attention, memory, and executive functioning. Although each of these processes is briefly described below, it is important to emphasize that in normal cognitive functioning these processes are related and interdependent. ³ For a more in-depth discussion of cognitive impairments following TBI, see Eslinger et al. ²⁰

Orientation/Arousal

Orientation refers to a person’s awareness of four spheres: person, place, time, and circumstance. Orientation to person pertains to autobiographic memory, that is, information that was acquired and stored prior to the onset of the injury. This information, along with knowledge of familiar places, does not need to be relearned or acquired but simply retrieved. The person and familiar place aspects of orientation typically return first in the sequence of orientation recovery. ²¹ Orientation to time, unfamiliar places, and circumstances requires the capacity to take in, store, and recall new information presented after injury. Of these three aspects of orientation, recalling circumstances returns first, followed by place and time. ²² Time (year, month, season, time of day) constantly changes, and therefore information must be continually updated, requiring an increased level of awareness and the ability to sequence and order ongoing events. The frontal lobes, which are commonly damaged in TBI, have been implicated in this process of time tagging.

Attention

Attentional problems range from mild to severe and, although they often resolve, they may persist years after injury. Concentration problems are a common post-TBI complaint of long-term survivors. Five dimensions of attention that have been described are (1) focused attention, which is the ability to respond discretely to specific visual, auditory, or tactile stimuli (for example, visually tracking an object); (2) sustained attention or vigilance, which is the ability to maintain a consistent behavioral response during continuous repetitive activities for more than a few minutes or seconds (for example, sorting shapes correctly); (3) selective attention, which is the ability to maintain a behavioral set in the presence of distracting extraneous stimuli (for example, reading the newspaper with a television or music playing in the background); (4) alternating attention, which is the ability to shift the focus of attention and move between tasks with different behavioral requirements (for instance, a waitress serving tables and also working the cash register); and (5) divided attention, which is the ability to respond simultaneously to multiple task demands (such as driving while talking on a cell phone). Attention and working memory (discussed below) have fundamental roles in cognition; consequently, impairments in these processes restrict the extent of adaptive behavior and compromise all aspects of daily living. ²⁰

Memory

Memory deficits are common and often persistent among individuals with TBI. Studies indicate that 54 to 84% of individuals diagnosed with severe TBI demonstrate memory difficulties. Nearly 80% of families of TBI survivors report persistent memory impairments as long as 7 years after injury. ^{23,​ 24} It is important to understand the mechanism underlying the memory deficit. Difficulties can occur in learning new information (i.e., acquisition or encoding), storage of learned information, or retrieval of information. ²⁵ DeLuca and colleagues reported that the majority of memory deficits secondary to TBI are attributed to acquisition and encoding deficits. Although memory deficits may occur in isolation, they are typically accompanied by deficits of other cognitive abilities, such as orientation, attention, and language. Using this generic model of memory, various deficits can be classified by stage of memory implicated, for example, memory problems secondary to attention deficits. Difficulty with any level of attention prohibits complete processing of information for subsequent recall. Memory problems that are secondary to encoding deficits may result from impaired language or perceptual ability; in other words, if the individual does not understand or perceive what was presented, memory of that information is reduced. Memory problems related to storage may be the result of a decreased ability to put or to keep information in memory. The distinction between long- and short-term memory is based on the duration of memory store and the capacity of the storage. Long-term memory holds information indefinitely and has unlimited capacity. By comparison, short-term memory is of short duration and limited capacity. Working memory is similar to short-term memory, with the exception that working memory is dynamic, that is, it is a system that allows information that is presently in use to be held and manipulated. Individuals demonstrating storage problems may have normal short-term and working memory, although their long-term memory may be reduced due to a progressive deterioration of retained information over time.

Executive Functioning

The frontal lobes coordinate input from all other regions of the brain and are important for coordinating and actualizing activities involved in cognitive processing, often referred to as executive functioning (EF). The neural underpinnings of EF primarily include the prefrontal cortex, which has numerous interconnected cortical and subcortical structures forming neural networks. ²⁰ EF metacognition, or self-regulation, ²⁶ more than any other cognitive dimension, determines the extent of social and vocational recovery. ^{3,​ 27} EF is not a discrete process but rather an umbrella function that interacts with all realms of cognition. EF may be considered a composite of the activities related to goal-directed behavior, including initiation, planning, sequencing, organization, and regulation of behavior. Individuals with deficits in the area of EF may be able to perform single-step operations but may be unable to plan, sequence, and monitor multistep activities; for example, they may be able to answer the phone in an office but be unable to function as an office manager.

Awareness of Deficits

Unawareness of deficits, or anosognosia, is a common problem following brain injury—some reported rates are as high as 40%—and can be a significantly limiting factor to cognitive and clinical outcomes after TBI because of inconsistent participation in rehabilitation services. ^{28,​ 29,​ 30} The degree of cognitive impairment and site of lesion are predictive of awareness deficits in the stroke population, with anosognosia being more common after anterior lesions and cortical lesions versus subcortical lesions. ³¹ Unawareness should be distinguished from denial, which is a subconscious process that spares patients the psychological pain of accepting the serious consequences of a brain injury and its unwanted effects on their life. ³² There are a variety of models of unawareness. The first model includes potential sources of unawareness, such as (1) the individual may not have enough information or the ability to comprehend the information; (2) the individual may have the information, but not be able to appreciate the implications of this information; or (3) the individual has the information and is able to acknowledge the implications, but ignores the information to lessen the emotional pain. ³³ The second model pertains to types of awareness, including (1) intellectual awareness, which refers to the individual’s ability to understand that a particular function is impaired; (2) emergent awareness, which is the ability to recognize a problem while it is actually happening, which incorporates the ability to monitor the relationship between one’s actions and the environment; and (3) anticipatory awareness, which is the ability to anticipate that a problem will occur as the result of some deficit and depends on intact intellectual and emergent awareness. ³² The final model involves varieties of awareness deficits, that is, unawareness due to (1) cognitive impairments, in particular problems with memory and reasoning; (2) psychological reactions; and (3) an inability to recognize deficits in functioning due to severity of brain damage. ²⁸

7.5.3 Language Disturbances

Aphasia

The vast majority of TBI survivors do not present with aphasia. ^{34,​ 35,​ 36}As noted by Duff and colleagues, ³⁷ early investigations focused on identifying patterns of communication deficits that distinguished individuals with TBI from those with aphasia, and on selecting appropriate assessment procedures to characterize their difficulties with functional communication. Use of aphasia batteries, which evaluated vocabulary and grammatical abilities at the single-word and sentence levels, was not sensitive to the subtle nature of these impairments. Holland ³⁸ noted that there is overlap in the deficit areas between aphasic and individuals with TBI. However, it is the qualitative differences in the naming errors between the two groups that may be most useful in distinguishing between aphasic and nonaphasic responses. Both aphasic and individuals with TBI produce circumlocutions and various paraphasias and have reduced fluency in the generation of category-specific words; individuals with TBI, however, demonstrate additional naming errors. For example, individuals with TBI may also produce naming errors related to their personal situations or make errors of confabulation (bizarre responses related to the patient’s disorientation). For further information on differential diagnosis of language disturbance, see Chapter 4.

Confused Language

In addition to specific linguistic deficits, individuals with TBI may also demonstrate significant problems in the area of what has been termed confused language. ^{11,​ 39,​ 40,​ 41} Confused language is described as receptive/expressive language that may be phonologically, syntactically, and semantically intact, yet lacking in meaning because responses are irrelevant, confabulatory, circumlocutory, or tangential in relation to a specific topic, and lacking a logical sequential relationship between thoughts. ⁴² Such language dysfunction may be mistaken for a fluent aphasia but is more appropriately considered cognitively based as opposed to linguistically based, that is, as a symptom of cognitive rather than linguistic deficits. More recent considerations of language disruption following TBI have advocated using the term cognitive-communicative disorders because it is thought to be a more accurate description of such impairments. Cognitive-communicative disorders involve difficulty with any aspect of communication secondary to cognitive dysfunction (e.g., attention, memory, executive functions). ⁴³

Pragmatics

Occasionally individuals with TBI exhibit language disorders most consistent with aphasia, and many, particularly in the acute stages of recovery, demonstrate language behavior consistent with confused language. However, the primary basis of language dysfunction in the majority of individuals with TBI pertains to disordered language use or pragmatics. Pragmatics refers to a system of rules that structures the use of language in social context. Holland ³⁸ has observed that whereas individuals with alphasia may communicate better than they talk, individuals with TBI appear to talk better than they communicate. Pragmatic deficits are most prevalent in those individuals with injuries to the prefrontal cortex (PFC). The PFC is involved in coordinating and actualizing many functions involved in cognitive processing such as attention, motivation, regulation, and self-monitoring. ⁴⁴ Individuals with damage to the PFC demonstrate difficulties with formulation of discourse not attributable to aphasia. ⁴⁵ Alexander and colleagues ⁴⁶ note that individuals with prefrontal injury also demonstrate problems with inappropriate social interactions (e.g., difficulty interpreting social cues), and abstract forms of language (e.g., irony or sarcasm).

7.5.4 Speech Disturbances

Dysarthria, Apraxia of Speech, and Mutism

It has been estimated that approximately 30% of TBI survivors present with some type of dysarthria. ^{47,​ 48} Clinical experience and isolated case reports ⁴⁹ indicate that the apraxia of speech (AOS) of individuals with TBI is comparable to the AOS resulting from left hemisphere strokes, and that it usually occurs in conjunction with a language disorder. For more detailed information pertaining to the management of motor speech disorders see Chapter 9.

Levin and colleagues ⁵⁰ have defined a condition, called mutism, secondary to severe TBI but not attributable to cranial nerve injury, in which the patient has no speech in the presence of an ability to comprehend simple commands and to communicate nonverbally. These investigators observed the incidence of mutism in a group of 350 TBI patients to be approximately 3%. Two types of mutism were identified, one associated with lesions to the left basal ganglia (subcortical structures deep within the brain), believed to have a better prognosis, and another associated with severe diffuse brain injury, considered to be a permanent condition.

7.6 Rehabilitation of Traumatic Brain Injury

Rehabilitation has been defined as the development of an individual to the fullest physical, psychological, social, vocational, avocational, and educational potential consistent with his or her physiologic or anatomical impairment and environmental limitations. ⁵¹ A primary objective in the rehabilitation of individuals with TBI is the improvement of social skills. The ability to communicate effectively is the basis of socially skilled behavior. Although there is no universally accepted definition of social skills, Ylvisaker et al ⁵² have suggested that social skills consist of five dimensions: (1) the individual’s knowledge of self; (2) the extent to which individuals attend to their personal appearance; (3) social cognition (i.e., social perception, social knowledge, and social decision making); (4) communication; and (5) the social environment (i.e., important people in the individual’s natural environment). Rehabilitation of TBI is best described from the perspective of the World Health Organization’s (WHO) International Classification of Functioning and Health (ICF). From the perspective of brain injury, pathophysiology is the interruption of normal physiologic processes, body functions, or structures through injury or disease. Impairments are losses or disorders of cognitive, emotional, or physiologic functions. Activity/functional limitations result from impairments, and refer to the effects of the impairments on a person’s everyday life activities. Participation is the nature and extent of a person’s involvement in life situations in relation to impairments, activity limitations, health conditions, and contextual factors ( ▶ Table 7.6). ⁵³ The ultimate determination of successful rehabilitation following TBI is the reintegration of survivors into their communities in a meaningful and satisfying social role. ^{2,​ 3,​ 54,​ 55,​ 56,​ 57}

7.6.1 Cognitive Rehabilitation

The treatment of cognitive-communicative deficits that result from TBI is referred to as cognitive rehabilitation. This term implies an intervention regimen aimed at increasing functional abilities in everyday life by improving an individual’s capacity to process and interpret incoming information. ⁵ In general terms, there are two approaches to cognitive rehabilitation: restorative and compensatory. ⁵⁸ The underlying rationales of these approaches are very different. The restorative approach is based on the notion that neuronal growth, resulting in improvement in function, is associated with repetitive exercise of neuronal circuits. The restorative approach is sometimes referred to as the “muscle-building approach” and involves repetitive exercises and drilling. In contrast, the compensatory approach concedes that certain functions cannot be recovered, and the development of strategies to circumvent the impaired functions is the primary goal. ⁵⁹ This view of cognitive rehabilitation implies that “restoration” and “compensation” are distinct phases of the rehabilitation continuum. In other words, compensatory strategies should not be implemented until restorative exercises have failed. However, it has been observed that helping individuals with TBI to become increasingly aware of their cognitive needs and to be strategic in approaching cognitively demanding tasks, which is typically associated with a “compensatory” approach to cognitive rehabilitation, is actually restorative. In other words, the compensatory strategy actually focuses on restoring the strategic, deliberate aspect of cognitive processing, which may be more important after the injury than before. Therefore, it is misleading to contrast “restorative” and “compensatory” as though they were not overlapping approaches. Rather, these approaches should occur simultaneously in rehabilitation. ^{60,​ 61}

Currently there is disagreement regarding the most effective approach to cognitive rehabilitation. The traditional approach, termed “process-specific,” consists of hierarchically organized treatment tasks targeting distinct, theoretically motivated components of cognitive processes ^{3,​ 5} and has been the most widely applied technique. In recent years context-sensitive approaches have been advocated in which treatment is provided by collaborating with people in the daily environments of the person with TBI to create positive, supported everyday routines of action and interaction in the context of daily activities. ⁶¹ The application of specific instructional techniques in cognitive rehabilitation is also currently being investigated. ⁶² A great deal of research remains to be done to validate cognitive and communicative rehabilitation interventions for individuals with TBI. Concrete patient-specific decision-making is critical to the development of a body of evidence supporting interventions for this population. ⁶³

Recently, a national trend of referencing research evidence to support clinical decision making for the management of medical conditions has surfaced. Consistent with this movement, the Academy of Neurologic Communication Disorders and Sciences (ANCDS), in conjunction with the American Speech-Language-Hearing Association’s (ASHA’s) Special Interest Division 2 (Neurophysiology and Neurogenic Speech and Language Disorders), established committees of experts to develop evidence-based practice guidelines (EBPG) for the management cognitive-communication disorders following TBI. The committee developing the EBPGs for TBI identified several assumptions about the nature and management of cognitive-communication disorders following TBI ( ▶ Table 7.7). ⁶⁴ Recently, the Department of Defense requested the Institute of Medicine (IOM) to assemble a committee of experts to comprehensively evaluate the benefits of cognitive rehabilitation as a therapeutic intervention for TBI. This initiative was in response to the designation of TBI as the “signature wound” of the conflicts in Iraq (OIF) and Afghanistan (OEF) and that thousands of injured service members with TBI were facing long-term challenges involving return to their families and communities. When the review was completed, a summary report was submitted to IOM (see Committee on Cognitive Rehabilitation Therapy for Traumatic Brain Injury ¹). The committee found no studies addressing cognitive deficits in the acute stage of recovery, few studies pertaining to treatment of those with moderate-severe TBI in the subacute time period, and few studies focused on mild TBI in particular. There was evidence supporting the efficacy of cognitive rehabilitation for individuals with moderate-severe TBI in the chronic phase that varied by cognitive domain and specific treatment technique. Many of the limitations in the evidence were secondary to methodological flaws in the studies reviewed. Therefore, the committee concluded that the findings did not discount meaningful benefit of cognitive rehabilitation for TBI. The committee advocated for the ongoing application of cognitive rehabilitation for cognitive and behavioral impairments secondary to TBI.

7.6.2 Planning for Cognitive Rehabilitation

In planning for cognitive rehabilitation, it is necessary to consider the long-term needs of the individual with TBI. This process is facilitated by answering the following questions: Are the treatment goals realistic? What is the individual’s capacity to benefit from treatment? According to Lezak, ⁶⁵ the identification of realistic treatment goals requires the evaluation of two aspects of the injured individual’s cognitive behaviors: the capacity for taking an abstract attitude and the status of executive functioning. Abstract attitude refers to such capacities as appreciating the point of view of others, being aware that there is a world beyond one’s own personal perspective, and being free of concrete or literal interpretations of daily experience. As discussed previously, executive functioning involves the capacities necessary to have an intention and thus to formulate goals, to plan and organize goal-directed behavior, to carry out an effective plan, and to monitor and self-correct one’s behavior as needed. ^{66,​ 67} Unfortunately, unlike some cognitive deficits that improve with rehabilitation, an impaired capacity to take an abstract attitude and impairments of executive functioning may often become chronic problems that are resistant to treatment. Retraining these capacities requires the individual to have in mind what no longer comes to mind, or what that individual no longer appreciates as missing. Generally speaking, the major limitations to an individual’s ability to profit from rehabilitation are (1) impaired executive functioning, (2) loss of abstract attitude, (3) chronic attentional and/or memory disorders, and (4) learning deficits. ⁶⁵ In addition, disorders of behavioral self-regulation and social-interactive competence are common after TBI and may further limit an individual’s capacity to benefit from cognitive rehabilitation. ⁶⁸

Rehabilitation after TBI should be driven by the individual’s real-world problems and not deficits identified by a test, as such deficits are “often far removed from the everyday manifestations of a deficit.” ^69(p25) Goal planning is a preferred alternative that has been used in rehabilitation settings for several years. This approach is based on several principles: (1) the individual with TBI should always participate in goal setting, (2) goals selected should be reasonable and client-centered, (3) the goal should contain a description of the individual’s behavior when the goal is attained, (4) the method for achieving the goal should be clearly delineated, and (5) all goals should be specific and measurable with definite timelines. The list of goals will consist of both long- and short-term objectives. ^{69,​ 70}

7.7 Stages of Recovery After Traumatic Brain Injury

The usual course of recovery following a TBI typically involves a period of unconsciousness, followed by confusion, and a progressive return of cognitive functions. The timeline of these stages is variable among individuals with TBI and consequently it is impossible to specify a regular course of recovery among the TBI population. ⁵ A more practical approach is to discuss stages of recovery. In the subsections that follow, a variety of issues pertaining to the management of individuals with TBI, and specifically the role of the SLP, are discussed with regard to the early, intermediate, and later stages of recovery. These stages are based loosely on ratings from the Rancho Los Amigos Levels of Cognitive Function (RLA) ( ▶ Table 7.8). ⁷¹ This scale is useful for identifying a patient’s most intact level of cognitive functioning over the entire course of rehabilitation. The RLA is used to identify the patient’s highest level of functioning and therefore is indicative of the best way to approach the patient throughout the continuum of intervention. The RLA represents a progression of recovery of cognitive abilities in the TBI population as manifested through behavioral change. Advantages of using the RLA include (1) that it is an assessment that does not require the patient’s cooperation; (2) it provides behavioral descriptions of cognitive recovery along a severity continuum; (3) it enables professionals from a variety of disciplines to discuss TBI patients using common and descriptive terminology; and (4) it provides baseline information for the development of team treatment goals. For each level, assessment and treatment procedures are discussed as well as the rationale for the approaches selected. The discussion of each level is followed by a brief case study of an individual at that level of functioning.

7.7.1 Early Stage of Recovery (RLA II, Generalized Response; RLA III, Localized Response)

Assessment/Treatment

During this phase of recovery, communicative functioning is dependent on arousal mechanisms; consequently, management procedures are often diagnostic in nature and assessment and treatment become simultaneous endeavors. ⁷² There are two types of variables that need to be considered in the assessment of minimally responsive brain-injured patients: task and performance. Task variables are within the clinician’s control and include such things as (1) stimulus intensity, (2) rate of presentation, (3) type of stimulus presented and type of response required (receptive versus expressive), (4) duration of task and length of testing sessions, (5) familiarity of task to patient, (6) level of task complexity, and (7) context in which stimulus is presented. Performance variables are aspects of the response the clinician observes while task variables remain constant or change. These include such factors as (1) response duration, (2) response delay, (3) ability of the patient to shift response sets from one task to the next, (4) number of times a response needs to be repeated for the response to be elicited, (5) type of response, and (6) pattern of responses, or response consistency. With regard to assessment of cognitive-communicative skills in the early stages of recovery, the SLP must rely primarily on observational skills, because TBI patients at RLA II and III are typically unable to participate in standardized testing. Attempts should be made to “standardize” the observations by presenting comparable stimulation across input modalities (e.g., auditory, visual, tactile) and consistent stimulation activities (i.e., with regard to rate, complexity, duration, intensity, etc.) across sessions. By using replicable stimulation, responses observed in one session under a specific pattern of stimulation can be attempted to be elicited again under the same conditions during another session as a measure of the consistency of the response. The Western Neuro Sensory Stimulation Profile ⁷³ and the JFK Johnson Rehabilitation Institute’s Coma Recovery Scale, ⁷⁴ which were designed to assess TBI patients’ arousal/attention, expressive communication, and response to auditory, visual, tactile, and olfactory stimulation, are examples of attempts at standardizing observations of lower-functioning patients ( ▶ Table 7.9). It should be noted that sensory or coma stimulation has generated a great deal of controversy in the field of brain injury rehabilitation (see Zasler et al ⁷⁵ for a review and recommendations for its use).

For the purposes of establishing a system for communicative interactions, once patients with TBI are responding in a more consistent fashion, their best input modality and best response mode need to be identified. Such information should be immediately communicated to the other treating team members and the patient’s family members to facilitate their interactions with the patient. DeRuyter and Becker ⁷⁶ observed that for nonspeaking individuals functioning at RLA III (localized response), the success of yes-no response systems depended on the most natural and automatic body movement. The most successful yes-no systems were head nods, with decreasing success noted for systems requiring less automatic movement and the use of other cognitive and/or motor processes (e.g., visual tracking and reading or using yes-no cards). The ability to follow verbal commands in individuals who have been unresponsive has been noted to be a significant turning point in patients’ progressing out of coma. ⁷⁷ Ansell and Keenan ⁷³ have reported on patterns of communication recovery in “slow to recover patients” (at RLA II and III for extended periods of time). They observed that, if responses to auditory information (following commands) began to improve, the patient had a 50% chance of progressing to RLA V. If responses to auditory and visual information returned simultaneously, the probability of improving to RLA V was considerably better. If, however, responses to visual or tactile stimulation were the only responses to emerge, the likelihood for cognitive improvement was minimal. These results are consistent with previous research that has indicated retardation of development and diminished recovery of central nervous system function in the presence of environmental and sensory deprivation. ⁷⁸ It also emphasizes the importance of the cognitive-linguistic system to recovery after TBI.

Case Study 1

Background LD is a recent college graduate who works in the sales department of a daily newspaper. She was involved in a motor vehicle accident in which her vehicle struck a utility pole at a high speed. At the time the paramedics arrived, her GCS was 6; by the time she arrived in the emergency department, her GCS was 3. Examination revealed multiple trauma, including facial and chest contusions that required her being intubated for assisted ventilation. Computed tomography (CT) scan revealed a basilar skull fracture and multiple contusions in both hemispheres. She was admitted to the neuro–intensive care unit (ICU) and over the next 24 hours considerable cerebral edema occurred, requiring the insertion of an intracranial pressure (ICP) monitor. After approximately 5 days, the brain swelling subsided and the ICP monitor was removed. It was at this point that the initial referral for a speech-language pathology consult was made.

Assessment/Treatment When LD was first seen, she was still in the ICU. She was no longer intubated but was minimally responsive (RLA II, generalized response) and had a nasogastric feeding tube in place. No consistent responses could be elicited, and consequently no formalized testing was completed. Following the initial assessment session, LD was scheduled for three 10- to 15-minute diagnostic treatment sessions per day. She was routinely more responsive in the early morning and was most easily aroused by auditory stimuli, particularly recordings of family members saying her name. LD’s eyes remaining open typically signaled changes in her level of alertness. Once a consistent response to the audio recordings was noted, attempts were made to attain and maintain her arousal with different types of auditory stimuli.

After approximately 10 days in the ICU, LD was transferred to a regular room on a neurosurgical unit. Nursing, physical therapy (PT), and occupational therapy (OT) staff members also incorporated sensory stimulation activities into their treatment regimens. Family members were also able to provide carryover with the stimulation activities on the weekends. An important aspect of these activities was a daily journal, which was kept in LD’s room and was used to record the characteristics of the stimulation applied and the consistency of her responses. This facilitated communication between treatment team and family members. At approximately 5 weeks posttrauma, LD’s responsiveness had increased to the point where she was inconsistently responding via head nodding to yes-no questions and was attending to visual stimuli as well. No consistent vocalizations were noted, nor had anyone observed any verbalization. Her RLA level was rated at II to III.

After nearly 7 weeks of acute care, LD’s medical condition stabilized, and she was transferred to a rehabilitation hospital for more aggressive rehabilitation services. She continued to be tube fed via a percutaneous endoscopic gastrostomy (PEG) that had been implanted after 12 days because LD had developed a severe nasal irritation from the nasogastric (NG) feeding tube. Prior to leaving the acute hospital, LD was seen for a swallowing evaluation (via fiberoptic endoscopic evaluation of swallowing [FEES]) that revealed aspiration of thin liquid and puree consistencies. A follow-up swallowing evaluation was recommended in approximately 2 weeks, or sooner if her cognitive status improved.

7.7.2 Intermediate Stage of Recovery (RLA IV, Confused-Agitated; and RLA V, Confused-Inappropriate-Nonagitated)

Assessment

As the alertness of individuals with TBI at RLA IV (confused-agitated) and V (confused-inappropriate-nonagitated) improves, they are bombarded with a multitude of stimuli from their environment. Because they are unable to focus and sustain attention for more than a few seconds, the stimuli may be meaningless or at best confusing. Consequently, these patients may demonstrate marked agitation. Their arms, legs, trunk, and head may be in constant motion and speech is often completely irrelevant beyond a few automatic social responses. The term confusion is usually applied to such pervasive attentional deficits. This period is almost always reversible in TBI patients; however, in some severely injured patients confusional states may become chronic. ⁵ With time, less agitation is noted, but TBI patients may still be unable to maintain a coherent line of thought or maintain concentration. Severe disruption of language function at this stage is common, even in the absence of aphasia. Confused language, described previously, is the best characterization of the cognitive-communicative impairments. Impaired attentional processes, including initiation, maintenance, shifting, and inhibiting (i.e., the ability to ignore distractions), affect both language comprehension and expression. Poor topic maintenance and topic shifting in conversation and stimulus-bound responses result from ideational perseveration (i.e., becoming fixated on certain ideas or thoughts), verbal disinhibition (i.e., saying whatever comes to mind), and impaired impulse control. ^{42,​ 79} In the presence of damage to the frontal lobes, which is a relatively common consequence of TBI, it has been observed that although the structural components of language remain intact, the intent and use of language may be significantly impaired. ^{44,​ 46,​ 80} Language behaviors associated with frontal lobe injuries include confabulation, impaired word fluency, perseveration of thought, inappropriate turn taking, inattentiveness to listener’s needs, repetitive and/or disorganized messages, and social inappropriateness due to poor self-monitoring.

Kennedy and DeRuyter ⁷² noted that because individuals functioning at RLA IV and V are frequently unable to focus and sustain their attention to specific tasks, to discriminate, and to sequence and organize their responses, nonstandardized procedures must be employed during their assessment. Adamovich et al ⁷⁹ presented several activities arranged in a hierarchy from low-level (arousal and alertness) to high-level (reasoning and abstraction) cognitive tasks. Although use of standardized materials is not always practical, baseline data gathered as early as possible can document the pattern of recovery and provide evaluation as soon as possible. The ANCDS committee developing the EBPGs for TBI has offered several guidelines for the use of standardized batteries for the assessment of cognitive-communication disorders ( ▶ Table 7.10).

Treatment

In the intermediate stage of recovery, RLA IV (confused-agitated) and V (confused-inappropriate-nonagitated), traditional cognitive rehabilitation and speech-language management, as needed, may be initiated. Process-specific cognitive retraining is frequently initiated at this stage; this treatment approach is characterized by “repeated administration of hierarchically organized treatment tasks that target distinct, theoretically motivated components of cognitive processes.” ^{5(p. 2)} The ANCDS committee on EBPGs for TBI recently reviewed the available evidence on the effectiveness of one such technique, direct attention training. ⁸⁷ ▶ Table 7.11 summarizes the clinical recommendations based on this review. Other EBPGs will be forthcoming.

In the beginning, individuals at this stage of recovery may be able to participate meaningfully only in individual sessions, as group sessions may be too distracting or overstimulating. As the client becomes more oriented and less confused, the one-on-one sessions may be supplemented by group therapy. Group intervention is useful for assessing generalization of targeted behaviors in a more natural setting (i.e., a setting full of competing stimuli, which is less structured and controlled). Group intervention is also very useful for social skills training. Social skills include a variety of abilities (e.g., conversing, sharing, cooperating, greeting others) that enable an individual to interact effectively with peers and others at home, in school, on the job, and in other environments. ⁵²

Individual and/or group treatment may also be supplemented by computer-assisted treatment. Computers are useful for the presentation of repetitive drills and can be programmed to provide varying levels of reinforcement. Computers can also record precise facets of the patient’s response, such as accuracy and delays. Computers may also provide a means of facilitating functional interactive activities, such as sending and receiving email. Family or significant other training/counseling, as well as interdisciplinary consultation and dismissal/discharge planning, is also ongoing during this stage.

Case Study 2

Background MD is a young man who is employed as a cabinetmaker. The motorcycle he was driving was struck by a car. He was not wearing a helmet and suffered a severe closed head injury. Upon admission to an acute care hospital, MD was unconscious, and CT scans revealed multiple bilateral cerebral contusions in the frontal, temporal, and occipital lobes. In addition, MD sustained numerous orthopedic and facial injuries, along with a collapsed lung. He remained comatose for approximately 5 weeks, and once he emerged from the coma, he remained in a confused and agitated state (RLA IV) for nearly 3 months. Once MD eventually progressed to RLA V (confused-nonagitated) he remained at that level for nearly 6 months and never progressed beyond RLA VI (confused-appropriate).

Assessment At approximately 2 months after his injury, MD was transferred to a rehabilitation hospital. Upon admission, cognitive-communicative assessment was difficult because of his agitation. With time it became apparent that he did not have dysphagia, dysarthria, or aphasia, but he did demonstrate cognitive-communicative deficits characterized by very severe impairments in attention, memory, and executive functions. MD also demonstrated significant problems with balance and gait, as well as visual perception.

Treatment Interdisciplinary treatment was initially focused on management of his agitation, whereas diagnostic therapy probed for cognitive abilities that could be used to develop compensatory strategies to circumvent MD’s significant cognitive-communicative impairments. Over the course of a few weeks, it was discovered that MD had premorbidly enjoyed rock music, and this was incorporated into treatment as a positive reinforcement. Once MD had passed through the agitated stage of his recovery, it was apparent that his communicative abilities were moderately limited. Conversational speech was characterized by frequent confabulations, poor topic management, and frequent disruptive topic shifts. Functional auditory comprehension was limited to short, simple messages, and reading and written expression were severely limited.

At approximately 6 months post-onset, MD was discharged to the home of his mother, from whom he had been estranged since he dropped out of high school at the age of 16. MD’s mother was obviously concerned about his well-being and took on his care and supervision. MD continued as an outpatient at the hospital in an interdisciplinary TBI day treatment program that met 5 days per week. Over the next 6 months, MD demonstrated very little progress in the cognitive-communicative domains but grew steadily stronger and began a series of job trials within the rehab facility. His performance in these trials was poor, but with moderate supervision he was able to complete certain tasks. Eventually, his former employer, a furniture maker, asked if MD could return to work for him. Although the rehabilitation staff was not optimistic, a job trial was arranged for MD at his former job site. It soon became apparent that MD had no safety awareness in handling tools and was unable to complete even the most basic tasks, such as sweeping the workshop, because of distractibility. Although his employer wanted to keep MD on, MD’s inappropriate social skills and disinhibition around customers finally led to the employer’s decision that the arrangement was not feasible.

At 2 years post-onset, MD’s mother died. MD, who had continued on with a modified day treatment program focusing on vocational and social skills training, was placed in a supervised apartment and began work in a sheltered workshop. At 3 years post-onset, his status was essentially unchanged, although he was being evaluated for more independent jobs in the workshop.

7.7.3 Later Stage of Recovery (RLA VI, Confused-Appropriate; RLA VII, Automatic-Appropriate; and RLA VIII, Purposeful-Appropriate)

Assessment

In the later stages of recovery, RLA VI (confused-appropriate), VII (automatic-appropriate), and VIII (purposeful-appropriate), an interdisciplinary collaborative approach to cognitive-communicative-behavioral evaluation is critical. For example, subtle deficits of attention and speed of performance may be delineated by neuropsychological assessment while the occupational therapist analyzes the individual’s behavior during activities of daily living. The SLP often analyzes the effects that impaired processes have on performance in daily activities and communication. ⁷²

Evaluation of individuals at RLA VI to VIII must be tailored to the person’s specific injury, severity level, and overall communicative needs. With individuals who are confused, disoriented, and have difficulty with learning (RLA V), assessment should focus on impaired processes (e.g., attention and memory) as well as attention to the impact of the deficits on everyday tasks. With regard to the direct measurement of such deficits, Levin et al ¹¹ developed the GOAT, a brief schedule of questions to measure posttraumatic amnesia and disorientation after TBI ( ▶ Table 7.2). Assessment of individuals at RLA VII and VIII displaying milder cognitive deficits but impairment in higher thought processes (e.g., organization, integration, executive functions) will require a more detailed task-specific evaluation in addition to determining the extent of impairment within underlying processes. The use of standardized tests is most appropriate for TBI patients in the later stages of recovery. Although there are numerous standardized batteries available that can be used for assessing individuals with TBI, few were designed specifically or normed for this population. Consequently, selection of standardized assessment batteries and interpretation of test data must be done with caution ( ▶ Table 7.10). The information collected from such tests can (1) provide baseline information to measure improvement, (2) help to differentiate deficits attributable to diffuse cognitive-communicative disorganization versus focal-specific symptoms, (3) facilitate the identification of primary and secondary processes responsible for communicative breakdown, and (4) identify the point at which remediation should begin. ⁷² Assessment tasks will logically involve many cognitive processes, making it difficult to isolate the role of a single process. However, formal assessment should attempt to estimate the degree of impairment in single critical processes, such as attention (alertness, arousal, processing speed, attention span, selective attention), discrimination, sequencing, organization (association and categorization), memory processes (e.g., retention span, retrieval mechanisms, recent versus remote, episodic, procedural, semantic), organization, integration, and ability to sustain goal-directed activities over time. ^{42,​ 72,​ 79}

As previously mentioned, an important aspect of the assessment process for individuals with TBI at both the intermediate and later stages of recovery is not only to assess performance in traditional testing environments but also to observe their performance during functional activities and in more natural environments. This aspect of the assessment is important because there are often significant differences between an individual’s performances across the two settings. Deficits that are not evident during formal testing are often apparent in unstructured everyday environments. ⁸⁸ For example, an individual with TBI may demonstrate concentration abilities that are adequate for functional reading comprehension when distractions are at a minimum. However, when this same individual attempts to read in a noisy/busy environment, concentration abilities may be significantly limited, thus leaving reading comprehension nonfunctional. Such a finding would be important for the planning of treatment programs. Because such observations are common among individuals with TBI, Ylvisaker and Feeney ⁶¹ have described an approach to assessment and treatment planning they have termed “ongoing, collaborative, contextualized, hypothesis-testing assessment.” (p.75) This approach is based on the notion that vocational/academic performance and social behavior of individuals with TBI is influenced by the contexts they are in; therefore, assessments and interventions must be contextually based. Collaboration among staff members, the individual, and family members adds information and facilitates compliance for the implementation of interventions. Individuals with TBI frequently present with complex profiles (i.e., premorbid disabilities, combinations of diffuse and focal damage, cognitive and behavioral impairments), and when these individuals demonstrate difficulties in the vocational, academic, or behavioral realms, there are a variety of possible explanations and corresponding interventions that may help for their problems. Without hypothesis testing it is very difficult to interpret task failure and to recommend the most effective intervention. This assessment approach is summarized in ▶ Table 7.12.

Sohlberg and Mateer ⁵ have noted that pragmatic deficits may be the most pervasive communication problem in adults with TBI. Traditionally, assessment of communication skills in individuals with TBI has involved the administration of a language battery, most of which were designed to diagnose aphasia, focusing on the assessment of vocabulary and grammatical abilities at the single-word and sentence levels. Hagan ⁴² has observed that individuals with TBI often appear to have minimal language impairments based on the results of such assessment batteries, yet demonstrate significant functional communication difficulties in natural environments. Several investigators have advocated the use of nonstandardized assessment procedures, specifically discourse analyses (see Coelho ⁸⁹ and Coelho et al ⁶⁸ for reviews). Discourse is a series of related linguistic units that convey a message. There are various types of discourse and each type has different cognitive and linguistic demands. Types of discourse include descriptions (listing static attributes or relations), narratives (conveying actions and events that unfold in time), procedures (providing instructions or directions in a specific order), persuasion (giving reasons or facts to support an opinion), or conversation (interacting with others). It has been suggested that discourse is the most natural and basic unit of normal verbal communication. ⁹⁰ Furthermore, accurate production or comprehension of a narrative requires a complex interaction of linguistic, cognitive, and social abilities that are sensitive to disruption following TBI.

Discourse analyses typically begin with the elicitation of a spoken narrative, ideally at least five sentences in length. The discourse narratives are audiotaped and transcribed verbatim. Once transcribed, the narratives are divided into basic units for analysis, such as T-units (i.e., independent clause plus any dependent clauses associated with it). Depending on the type of discourse and the focus of the analysis, a variety of levels of analysis are possible. For example, in a narrative story, at the sentence level, the number of T-units may be tallied as a measure of narrative length, or the number of subordinate clauses may be counted as an index of grammatical complexity. Across-sentence analyses may involve examining how speakers link meaning units across several sentences (e.g., complete or incomplete ties), referred to as intersentential cohesion. In story narrative analysis, episodes are examined as a measure of story grammar ability or discourse organization. Episode components are defined as information units pertaining to stated goals, attempts at solutions, and consequences of these attempts ( ▶ Table 7.13 lists examples of story narrative analyses). Additional analyses include productivity measures, such as total words produced or total speaking time; content measures, such as accurate content units; and measures of conversational speech, such as appropriateness of an utterance, or topic maintenance ( ▶ Table 7.14 lists examples of conversational analyses). A variety of pragmatic rating scales are also available, many of which may be used during observations of the individual with TBI or may be completed by family members, employers, teachers, etc. (see Appendix 7.1 [p. 96] for examples of pragmatic rating scales). Regardless of the discourse genre selected or the analysis procedure applied, McDonald ⁹¹ has stressed that communication disorders following TBI must be viewed in context, including the context of the person’s sociocultural background and experiences, and specific communicative contexts the individual is likely to encounter in everyday life.

Treatment

Whether treatment is based on hypothesis testing ⁶¹ or a process-specific intervention, ³ for individuals in the later stages of recovery (i.e., RLA VI, VII, and VIII) the final phase of remediation should be directed toward carryover of treatment objectives to home and community environments. Consultations with teachers, employers, and fellow workers take place in this stage of recovery. This is not to imply that programming for carryover begins during the final stages of treatment. Rather, to facilitate carryover of treatment objectives to nonclinical environments, contextualization of treatment (i.e., working on skills the individual with TBI needs, in the environment where they are needed) should take place as soon as it is feasible.

Sustained community reentry at the highest level of productivity, independence, and social adaptation that an individual is capable of is the ultimate goal of TBI rehabilitation. ¹¹⁰ Concerns have been expressed about the generalization of treatment gains demonstrated in clinical settings. Such concerns have risen from research indicating that individuals with TBI often demonstrate chronic memory problems and/or frontal lobe injuries. It has been suggested that functional gains are most easily achieved when cognitive remediation is performed in the client’s home and community involving activities of high interest to the individual. ¹¹¹ Numerous case reports of treatment intended to enhance daily living, educational, and vocational activities provided by professionals who travel to the TBI individual’s home, school, or job have cited positive results with regard to return to school ^{61,​ 112,​ 113} or gainful employment ^{71,​ 111,​ 114,​ 115}

Case Study 3

Background SN is a 28-year-old woman who was involved in a motor vehicle accident. She was employed as a head nurse on a surgical unit in a large urban medical center. She was also working on a master’s degree in counseling, worked part-time as a realtor, was the business manager for her brother’s farm, and, working with her brother, had built her own house. Immediately following her accident, SN was brought to the emergency department with multiple trauma, including fractures of her pelvis, both legs, clavicle, two ribs, and an arm. She was noted to be conscious at the scene of the accident and when she arrived in the emergency department. A CT scan revealed no evidence of focal lesion or obvious cerebral trauma. From that point forward, all medical interventions were directed toward SN’s orthopedic injuries. She was hospitalized for 6 weeks and eventually returned home where she had PT through home care and eventually on an outpatient basis. At approximately 6 months after injury, SN attempted to return to work on a part-time basis, but the attempt was unsuccessful. SN noted problems with fatigue and concentration, and her fellow workers noted occasional errors preparing medications for distribution and vague chart notes. At home, SN noted being easily distracted; for example, she was no longer able to read if the TV or radio was on. She was also having difficulty keeping up with her graduate coursework and her realty work, and she could no longer keep the books for her brother’s farm. Eventually, she took a leave of absence from her nursing job and gave up the other endeavors. When SN reported these difficulties to her neurologist, she was referred to a psychiatrist, who attributed her difficulties to posttraumatic stress. She was treated with antidepressants and psychotherapy for approximately 3 months. At 18 months after her accident, she was referred to a rehabilitation facility for evaluation of a “suspected TBI.”

Assessment On her initial visit, SN was seen by a neuropsychologist and an SLP, each of whom spent approximately 1 hour with her and noted problems with attention, memory, and organizational abilities. Problems with pragmatic skills were also noted. SN’s RLA level was VIII (purposeful and appropriate). When these findings were reported to her, she replied, “I’m so relieved, I knew I wasn’t crazy.” Subsequent diagnostic sessions focused on delineation of the functional consequences of these cognitive impairments. Upon completion of the neuropsychological and SLP assessments, both evaluators met to formulate a treatment plan for SN. A meeting was then scheduled with SN to review the suggested treatment plan and to solicit her input for identification of realistic treatment goals. It was at this point in the assessment process that a significant hurdle presented itself: SN was adamantly opposed to recruiting employers, fellow workers, or family members into the rehabilitation process. She said, “Everything I have, I’ve gotten on my own, through my own hard work. I can do this on my own.” After much discussion it became apparent that SN was very concerned about not being able to return to nursing if her employer knew she had a brain injury. Consequently, she would not agree to any observations at work or job coaching.

Treatment Treatment objectives included targeting complex attention and concentration, memory, and social/pragmatic skills. A contract was written for a trial period of treatment. The treatment program involved individual therapy in SLP for cognitive remediation, and in psychology to address psychosocial issues. Individual therapy was supplemented by a pragmatics group and by job trials within the rehabilitation center, during which SN took on several volunteer assignments under the supervision of a vocational rehab counselor. All participants in the treatment program signed the contract. Team meetings, which always included SN, were held every 2 weeks. Steady gains were made in SN’s cognitive functioning and in her acceptance of her cognitive limitations. After approximately 6 weeks she became an outspoken member of the pragmatics group, regularly challenging her male counterparts’ notions of a woman’s role in today’s world. At the same time, she had a very successful and meaningful experience volunteering in the recreational therapy department, where she accompanied individuals from the transitional living unit on community outings. She was noted to have a calm and patient demeanor and many of the residents gravitated to her.

SN’s treatment program continued for approximately 6 months. During that time she became a strong self-advocate, testifying in court in a case that was brought against her insurance company for denial of therapy coverage and failure to pay her disability benefits that nearly led to her losing her home. During this same time, SN reevaluated her career goals. She acknowledged that her chronic concentration and memory problems would not allow her to return to nursing in the same capacity she had prior to her injury. So she began to explore options with her treatment team and finally agreed to some community-based job trials through the Bureau of Rehabilitation Services. One of these trials, in a skilled nursing facility, led to a job offer for a part-time nursing position that SN eventually accepted. In that position she met a practicum coordinator for nursing assistants from a local community college who offered her a part-time teaching position. Because the physical demands of regular nursing were becoming too hard for her, SN accepted this position. Approximately 4 years after onset of her TBI, SN was still employed at the community college supervising nursing assistants in on- and off-campus training sites.

7.8 Conclusion

The success or failure of cognitive rehabilitation needs to be considered on a case-by-case basis. There are numerous factors that may affect this highly complex process. ^{20,​ 116,​ 117} For example, it is important to prioritize the individual’s problems on the basis of relationships to functional real-world outcomes, the likelihood of success, and interrelationships between deficits. A second issue pertains to how well the problems to be addressed in treatment are defined. It is important to define the problem in functional terms, including the frequency, duration, and environments in which the problem occurs, as well as the relationship between the problem behavior and other problems. Description of treatment is a significant factor as well. The intervention should be defined and operationalized, including frequency and duration, to provide a record of what was done and so that it can be replicated. Providing treatment in the environment or context that the problem occurs in facilitates generalization. Patient selection is another key issue in determining the effectiveness of cognitive rehabilitation. The TBI population is extremely heterogeneous; therefore, both patients who will benefit and patients who won’t need to be described. Such descriptions should include time since injury onset, severity of injury, age, and level of education. All prognostic statements need to be grounded in practice theory, and dynamics of learning and interface of individual differences require specificity (i.e., what works for one individual may not work for another). A final critical feature of cognitive rehabilitation is who is doing the treating. The disciplines providing cognitive remediation are diverse and include varying levels of expertise and training. There is need to consider credentialing, specialty recognition, and, at the very least, continuing education requirements.

7.9 Study Questions

1. 
   

   Describe three types of brain damage that may result from traumatic brain injury (TBI).

   
   
2. 
   

   What factors determine the severity of TBI?

   
   
3. 
   

   What are the main cognitive disturbances seen after TBI?

   
   
4. 
   

   Discuss the distinction between aphasia and confused language following TBI.

   
   
5. 
   

   What is the purpose of the World Health Organization’s (WHO) International Classification of Functioning and Health (ICF)? Define each ICF domain.

   
   
6. 
   

   Describe the restorative and compensatory approaches to cognitive rehabilitation and the underlying rationale for each.

   
   
7. 
   

   Describe the notion of goal planning as it pertains to TBI rehabilitation.

   
   
8. 
   

   What are some of the factors to consider when selecting a standardized battery for assessing an individual with TBI? Name two batteries that are appropriate for use with individuals with TBI.

   
   
9. 
   

   Why are discourse analyses better suited for the assessment of some individuals with TBI than aphasia batteries?

   
   
10. 
    

    Describe the ongoing, collaborative, contextualized, hypothesis-testing assessment approach. How does this approach differ from more traditional evaluation procedures?

Appendix 7.1 Examples of Pragmatic Rating Scales

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