COGNITIVE-COMMUNICATION
THERAPY IN TBI POPULATION:
FUNCTIONAL BASED INTERVENTION
AND GOAL PLANNING
2018 KSHA CONFERENCE – WICHITA, KS
OCTOBER 5, 2018
LESLEY TILLEY, M.S., CCC-SLP
FINANCIAL DISCLOSURE
• Full Time Position year round
NONFINANCIAL DISCLOSURE
• No financial or nonfinancial relationships exist with the
research or resources cited in this presentation.
https://vimeo.com/mindsmatter/joshsjourney
JOSH’S JOURNEY
OBJECTIVES
• The learner will be able to describe the community-based model
of intervention for persons with TBI.
• The learner will be able to list benefits and outcomes of this
approach to the TBI population.
• The learner will be able to demonstrate the process involved in
functional goal planning.
TRAUMATIC BRAIN INJURY DEFINITION
• Traumatic brain injury (TBI) is defined as sudden trauma,
such a blow or jolt to the head that disrupts the normal
function of the brain. The severity of a TBI may range
from “mild” to “severe”. (www.cdc.gov)
TRAUMATIC BRAIN INJURY DEFINITION
• A closed brain injury is trauma to the brain as a result of the brain being
violently shaken within the skull. (ex. Concussion)
• Penetrating head injury is trauma to the brain as a result of an object
being projected through the skull into the brain. (ex. Gunshot wound)
• Post-Concussion Syndrome is defined as a complex disorder in which
various symptoms — such as headaches and dizziness — last for weeks
and sometimes months after the injury that caused the concussion.
FACTS ABOUT TRAUMATIC BRAIN INJURY
Brain injury is known as the silent epidemic
Approximately 5.3 million Americans are living with a TBI-related
permanent disability
Every 23 seconds one person in the U.S. will sustain a TBI
Males sustain more TBIs than females (more than 1.5 times more)
Falls are the #1 cause of TBI
(The Essential Brain Injury Guides 2009)
SPECTRUMS OF BRAIN INJURY
(MILD, MODERATE, SEVERE)
Mild Brain Injury
A mild brain injury, also known as “concussion” is one in which
there is only a brief or momentary loss of consciousness if any
without any major complications. This is often followed by “postconcussion syndrome” that can include temporary headaches,
dizziness, mild mental slowing and fatigue.
Mild Brain Injury
The most important element in the management of mild brain
injury is recognizing that the symptoms are real and can be
treated.
Symptoms of mild brain injury almost always improve over 1-3
months.
Mild Brain Injury
Mild TBI may also result in word-finding difficulties, decreased
motivation, anxiety, depression, and irritability (Levin,
Eisenberg, & Benton, 1989; Sohlberg & Mateer, 1989a).
Symptoms following mild TBI are quite variable and may
include difficulty concentrating under distracting conditions or
problems managing tasks involving multiple demands.
Moderate Brain Injury
Results in a loss of consciousness usually lasting only
minutes or a few hours followed by a few days or weeks of
confusion.
It may be accompanied by brain contusions or hematomas.
Moderate Brain Injury
Persons sustaining a moderate brain injury will usually have
cognitive and psychosocial impairments that can last for many
months.
With treatment these individuals are generally able to make a
nearly complete recovery.
Severe Brain Injury
Severe brain injury almost always results in prolonged
unconsciousness or coma lasting days, weeks or even
longer.
Such persons often have brain contusions, hematomas or
damage to the nerve fibers or axons, and some may have
suffered from anoxia.
Severe Brain Injury
Persons who sustain a severe TBI can make significant
improvements in the first year after injury and can continue to
improve at a slower pace for many years, and will often be left
with some permanent physical, behavioral and/or cognitive
impairments.
Severe Brain Injury
The consequences of severe TBI can affect all aspects of an
individual’s life (socially, physically, psychologically).
(J Head Trauma Rehabil 1999)
This can include relationships with family and friends, as well
as their ability to work or be employed, do household tasks,
drive, and/or participate in other activities of daily living.
SEVERITY QUOTE
“Many professionals and family members feel that the severity
of the actual injury and the severity of the problems or
consequences do not necessarily match the strict definitions
of mild, moderate and severe.”
(The Essential Brain Injury Guide 2009)
https://askabiologist.asu.edu/brain-regions
AREAS OF BRAIN FUNCTIONS
AREAS OF
FOCUS FOR TBI
INTERVENTION
https://brainandcommunication.ca/who-benefits-from-speech-language-pathology/
COGNITIVE-COMMUNICATION DEFINITION
Impairments of communication related to linguistic and
nonlinguistic cognitive functions
LINGUISTIC:
NONLINGUISTIC:
SYNTAX
SEMANTICS
WRITTEN
READING
NONVERBAL MESSAGES
ATTENTION
PROBLEM SOLVING
REASONING
MEMORY
EXECUTIVE FUNCTIONING
ASHA 1996
80-100 PERCENT OF PEOPLE WHO HAVE A TBI ALSO HAVE A
COMMUNICATION DISORDER
https://simonefriedmansls.com/traumatic-brain-injury/4165463044/
COGNITIVE-COMMUNICATION
The goal of intervention in traumatic brain injury (TBI) is to
achieve the highest level of independent function for
participation in daily living.
Cognitive-communication treatment approaches in TBI focus
either on restoration of skills or compensation for
difficulties. Treatments can also be specific to retraining
discrete cognitive processing components.
Asha.org
SLP’S ROLE IN INTERVENTION WITH
TBI POPULATION
• Identify current communication barriers and if and how they
may affect job performance and provides or trains
rehabilitation strategies to minimize the impact of those
barriers in functional settings (Bonelli, Ritter, & Kinsler, 2007).
• Establish treatment programs to decrease the effects of
impairments in all aspects of communication.
SLP’S ROLE IN INTERVENTION WITH
TBI POPULATION
• Identify effective and functional supports to enable
individuals to be as independent and successful as possible.
• Facilitates carryover of treatment objectives within context of
environment.
COMMUNITY INCLUSION AFTER BRAIN INJURY
• The best rehabilitation happens in a setting where the
individual is most likely to reach his or her immediate goals.
• The optimal setting should be suited to the individual’s stage
in the recovery process.
(JANET WILLIAMS : COMMUNITY INCLUSION AFTER BRAIN INJURY(2015))
COMMUNITY INCLUSION AFTER BRAIN INJURY
• By participating in regular routines with the support of
rehabilitation professionals, individuals can make progress in
a real world environment.
• By supporting people at home by providing services needed
for self-sufficiency and community membership, there’s a
significant long-term savings.
(JANET WILLIAMS : COMMUNITY INCLUSION AFTER BRAIN INJURY(2015))
LITERATURE REVIEWS – EFFECTIVENESS OF
COMMUNITY BASED INTERVENTION
• Published 2010: Effectiveness of Community-Based Rehabilitation After TBI
for 489 Program Completers Compared With Those Precipitously Discharged
• Study Objective: Evaluate outcomes of home and community based
postacute brain injury rehab
• Conclusion to Study: Showed significant positive changes from admission to
discharge for those completed course of rehab compared to those
discharged suddenly, gains were maintained 3 and 12 months after
discharge
LITERATURE REVIEWS – EFFECTIVENESS OF
COMMUNITY BASED INTERVENTION
• Published 2004: Community Integration and Satisfaction With Functioning
After Intensive Cognitive Rehabilitation for TBI
• Study Objective: Evaluate the effectiveness of an intensive cognitive rehab
program (ICRP) compared to standard neurorehab (SRP) for persons with TBI
• Conclusion to Study: Intensive, holistic, cognitive rehab is an effective form
of rehab for TBI. ICRP participants over twice as likely to show clinically
significant improvement in community integration as those receiving SRP.
Improvement in overall neuropsychologic functioning
LITERATURE REVIEWS – EFFECTIVENESS OF
COMMUNITY BASED INTERVENTION
• Published 2017: TBI Case Study: Effectiveness of Home and Community-Based
Rehabilitation Services Using Consumer-Driven Goal Planning
• Study Objective: Identify level of functioning post injury and at discharge following high
intensity collaborative rehabilitation between therapists and the consumer. Use of
International Classification of Functioning (ICF) model for analysis.
• Conclusion to Study: This model of TBI rehabilitation proved effective for the individual as
he made substantial gains across expressive and receptive communication skills, physical
function, ADLs and IADLs, including management of finances and health maintenance
needs. Allowed individual to attain functional outcomes of their choosing resulting in an
overall increase in participation in society and improved quality of life. Additionally, this
individual achieved independent living in the community and maintained steady
employment for multiple years.
MODELS TO THERAPY APPROACH
MEDICAL MODEL
• Professional determining goals
• Uses objective, standardized
measures for methods of treatment
• Condition is labeled
• Options for control held by expert
or other representative
• Treated in separate facilities
INDEPENDENT LIVING MODEL
• Consumer driven goals
• Know themselves the best
• Right to make own decisions and
problem solve when mistakes occur
• Less emphasis on label of disability,
more on person’s strengths and
needs
• Nothing for me without me
approach
(The Essential Brain Injury Guide 2009)
BENEFITS AND OUTCOMES OF APPROACH
• Person centered
• Focus on strengths, not difficulties
• Goals set by the person, not the
professional.
• Related to functional skill in their
natural environment
• Life changing transition
• Measurable
• Achievable
http://careerfitone.com/for-students/abilities-and-the-whole-person/
EXAMPLE OF FUNCTIONAL BASED INTERVENTION
AND INDEPENDENT LIVING MODEL
Josh, 37 yrs old
Experienced a severe TBI in 2013 due to a MVA.
Received rehab services in a rehab facility in the TBI unit for 4
months.
Josh received speech therapy services on the HCBS waiver from
March 2014 to July 2018
JOSH’S GOALS
Long-term Goals:
• In 8 weeks, I want identify a counselor that has experience with TBI and
decrease mood swings/anger.
• In 8 weeks, I want to find a job.
• In 16 weeks, I want to live on my own.
• In 16 weeks, I want to be able to get out of the house more and do more
socializing.
• In 24 weeks, I want help communicating with my words for times when I
get stuck so I am able to interact with others in my community and at
work
• In 24 weeks, I want to have less frustration when I speak. I want to
communicate better when speaking with others.
Short-term Goals:
• In 24 weeks, I want to utilize targeted functional communication phrases with
familiar or unfamiliar communication partners with minimal cueing (I.e.,
question forms: "Can I use this?", social phrases, "slow down", "show me", "I
don't understand", "say it again").
•
In 24 weeks, I want to identify social communication targets and develop
strategies to utilize them in the community setting with less than 2 visual
prompts provided by the therapist.
•
In 16 weeks, I want to describe objects by providing information such as color,
shape, size, function, etc. with 70% accuracy.
•
In 16 weeks, I want to repeat up to 4 words in functional phrases/sentences
after a verbal model.
FUNCTIONAL GOAL PLANNING
• Related to function and impact on life
• Person-centered=positive outcomes
• Specific skill teaching to increase independence
• Written for individual to understand
• Measurable
• Achievable
• Time specific
• Relevant=more motivation by person
CASE STUDIES: FUNCTIONAL INTERVENTION
AND GOAL PLANNING
• Case studies with cognitive-communication barriers affecting real life
situations
• Create 2 long term functional goals and 2 short term goals for speech
therapy
• Identify 2 functional activities/tasks you’d incorporate in therapy that
addresses these goals
FUNCTIONAL GOALS
LONG-TERM
• In 24 weeks, I want to manage my own
SHORT-TERM
•
In 8 weeks, I will be able to follow a visual
support to recall medication management
information (amt, times, pharmacy, etc.) with 80%
accuracy.
•
In 8 weeks, I will be able to follow a written
sequence to search for apartments online with
minimal assistance provided.
•
In 8 weeks, I will be able to recall speech
intelligibility strategies without reminders.
•
In 8 weeks, when given a short paragraph, I will
answer comprehension questions given multiple
choice options with 80% accuracy.
medications.
• In 24 weeks, I want to move to my own
apartment.
• In 16 weeks, I want to be understood by my
friends, family and others.
• In 16 weeks, I want to understand what I am
reading in a book.
CASE STUDY #1:
46 year old female
Consumer has history of a brain tumor. Following surgery, consumer fell during a
seizure and sustained a TBI. Additional falls and a car accident resulted in multiple
concussions. – moderate TBI
Actively searching for employment.
Enjoys arts and craft activities, baking and spends a great deal of time with her
friends and at her church.
Not able to provide her own transportation and has very limited transportation options.
Filling out paperwork is harder due to word recall and written abilities.
Referred for speech therapy due to difficulty in the following areas: topic maintenance,
decision making and emotional control. As well as verbal and written language and
organizational skills.
CASE STUDY #2
42 year old male
Sustained his most recent brain injury in 2014 by falling while getting out of
bed. – moderate TBI
Medical History: Exhibits left side neglect, Spasticity in left arm and leg, causing
pain and tightness, which can impact participation in various activities.
Social: Has a close group of friends that he engages in activities with, such as
visiting sporting events, museums and camping. Regularly goes to the gym two
days a week for physical therapy activities.
Currently unemployed and requires others to transport him into the community.
Wants to live on his own in the near future.
Referred to speech therapy due to concerns in the areas of memory, cognition,
expressive and receptive language.
CASE STUDY #3
43 year old female
Involved in a car accident head on by a drunk driver – severe TBI
Medical History: Cannot see out of her right eye. Diagnosed with severe sleep apnea and
becomes tired quickly.
Not currently working, Volunteers at an elementary school in a 2nd grade classroom.
Social: Came home to live with parents and has two daughters who she speaks to frequently.
Consumer uses her computer to communicate with family and friends through e-mail. Recently
has started working on using her new iphone to increase contact with friends and family
independently. Consumer likes to play games, read, talk with others, attend horseback riding
lessons and attend her daughter’s sporting events.
Requires assistance with transportation.
Difficulty in the areas of: memory and cognition, attention, social pragmatics (repeating
messages, body language), and visual neglect.
CASE STUDY #4
24 year old female
Fell from balcony at a party – severe TBI
Medical History: Consumer just received communication device, depression and chronic
pain, uses wheelchair
Not currently working, would like to start volunteering at her community library.
Social: Came home to live with parents and siblings. Consumer likes to play games,
make jewelry, go shopping and watch movies.
Requires assistance with transportation. Needs assistance with scheduling public
transportation
Difficulty in the areas of: memory and cognition, problem solving, attention, expressive
aphasia, reading comprehension, medication management
CASE STUDY #5
22 year old male
Biking accident - mild TBI
Medical history: fatigue, chronic pain in legs
Social: wants to socialize more and begin dating, returned back to school taking
one online course, wants to return to college full time, likes to go out to eat
Relies on others to transport, would like to obtain driver’s license or ride his bike
again
Difficulty in areas of: processing language, attention, short-term memory, written
language
CASE STUDY #6
38 year old female
History of abuse - mild TBI
Working part time
Single parent with two children in elementary school
Social: involved in church and has two close friends, minimal family support
Driving on own
Difficulty in the areas of: managing schedules due to memory/organization,
social pragmatics: low voice volume, expressive language, budgeting
CASE STUDY #7
58 year old female
Multiple car accidents - mild TBI
Not currently employed, would like to begin volunteering
Lives at home alone
Social: involved in church, has grandkids she sees on a weekly basis, likes to
cook
Drives on own; however, car currently broke down
Difficulty in the areas of: social communication (controlling volume level,
interrupting), problem solving daily tasks, budgeting, executive functioning
CASE STUDY #8
16 year old male
Sports injury accident in 2017- mild TBI
Attends high school and would like to go to community college
Lives at home with parents and younger siblings
Social: likes to hang out with friends, play video games, art
Relies on parents and friends to transport; however, wants to drive on own
someday
Difficulty in the areas of: attention, short-term memory, social pragmatics:
making inappropriate comments, following a schedule, organization
CASE STUDY #9
25 year old male
Gunshot wound – severe TBI
Medical History: Uses a cane, history of seizures and migraines
Not currently working, wants to pursue employment
Social: Living in apartment, would like to start dating. Consumer likes to play
games, listen to live music
Requires assistance with transportation.
Difficulty in the areas of: cognition (problem solving), short-term memory,
expressive and receptive aphasia, pragmatics (interruptions, initiating, voice
volume).
CASE STUDY #10
60 year old male
Fell from ladder working on his house - severe TBI
Medical History: uses power wheelchair, severe depression, chronic pain
Not currently working
Social: Lives with wife at home. Likes to listen to audiobooks, watch/listen to the
news, social isolation
Requires wife and others to transport in the community, primarily to doctor’s
appointments.
Difficulty in the areas of: social pragmatics (maintaining conversations, low voice
volume), expressive and receptive language, immediate memory, problem
solving.
SHARE CASE STUDIES/GOALS/ACTIVITIES
CONCLUSION
• Involve individual as much as possible in their therapy journey
• Incorporate real life tasks in therapy goals related to functional daily living
skills
• Always be thinking of how to approach therapy goals to increase
independence and/or independent living
REFERENCES
Brain Injury Association of America, 2009. The Essential Brain Injury Guide Edition 4.0.
Rainbow Rehabilitation Centers, Inc., Livonia, MI.
Burleigh, S.A., Farber, R. S., Gillard, M. Community Integration and Life Satisfaction After
Traumatic Brain Injury: Long-Term Findings (1997). The American Journal of Occupational
Therapy, 45-52.
Coelho, C.A., DeRuyter, F., Stein, M. Treatment Efficacy: Cognitive-Communicative Disorders
Resulting From Traumatic Brain Injury in Adults (1996). Journal of Speech and Hearing
Research Vol 39, S5-S17.
REFERENCES
Irwin M. Altman, PhD, MBA, Shannon Swick, MA, Devan Parrot, BS, James F. Malec, PhD,
ABPP-Cn, Rp. Effectiveness of Community-Based Rehabilitation After Traumatic Brain Injury for
489 Program Completers Compared With Those Precipitously Discharged (2010). Arch Phys
Med Rehabil Vol 91, 1697-1704.
Keith D. Cicerone, PhD, Tasha Mott, PhD, Joanne Azulay, PhD, John C. Friel, PsyD. Community
Integration and Satisfaction With Functioning After Intensive Cognitive Rehabilitation for
Traumatic Brain Injury (2004). Arch Phys Med Rehabil Vol 85, 943-950.
REFERENCES
Williams, J. Community Inclusion after Brain Injury: busting myths, revealing reality (2015).
http://communityworksinc.com/janets-blog/
Williams, J., Bates, E., Boswell, L. (2018). TBI Case Study: Effectiveness of Home and
Community-Based Rehabilitation Services Using Consumer-Driven Goal Planning. Poster
presented at Brain Injury Across the Age Spectrum: Improving Outcomes for Children and
Adults, NABIS, Houston, TX.
THANK YOU FOR
PARTICIPATING
IN THIS SESSION TODAY!
Lesley Tilley, MS, CCC-SLP
lesleyt@mindsmatterllc.com