Traumatic Brain Injury:
Are you interested?
February 5, 2011
TBI: What SLPs Should Know
• The Speech Language Pathologist’s (SLP)s
role in working with patients with
Traumatic Brain Injuries (TBI)
• Lower level patients
• Higher level patients
• Family involvement
Linda Hertz Shively
MA CCC SLP
• Kentfield Rehab and Specialty Hospital
• Per diem work at about 10 hospitals
• Transitions of Berkeley/Learning Services
at Berkeley
• The Greenery Rehab Hospital
Traumatic Brain Injury:
–Strokes
• Focal damage
• Blockage or break in an artery
Traumatic Brain Injury:
Diffuse Damage
Point of impact
Contra coup damage
Twisting of the brain stem
Sheering on the sinuses
Swelling
Traumatic Brain Injury:
Age
o Neuroplasticity of the brain
o Motivation
o “The parents” vs. “My child”
o Larger support system
Traumatic Brain Injury:
The Result
Communication
Cognition
Rancho Los Amigos Cognitive Scale
-Revised
Lower levels
vs.
Higher levels
Rancho Los Amigos Cognitive Scale
-Revised
Level one: No response: Total
Assistance
•To stim
•To painful stim
Rancho Los Amigos Cognitive Scale
-Revised
Level Two: Generalized Response:
Total Assistance
–Generalized Response
–Spontaneous movement
Rancho Los Amigos Cognitive Scale
-Revised
Level Three: Localized Response:
Total Assistance
–Localized Response
–Beginning to follow commands
–Spontaneous movements
–Reflexes
SLP’s role:
–Personally relevant
–Differentiate between Spontaneous
vs. Volitional
–Improvement = therapy time
–Educate other Professionals
–Family
Volitional and Spontaneous
Movements: Difficulty in Assessment
1. Spontaneous movement
2. Roving eye movements
3. Not motorically capable
4. Reduced attention
5. Distractible to environment
Volitional and Spontaneous
Movements: Difficulty in Assessment
6. Reflex
7. Delayed responses
8. Apraxia
9. Saturated
10. Seizures
How to Assess
Volitional vs. Spontaneous Movement
–The patient must be alert
How to Assess Volitional vs.
Spontaneous Movement
• Standardized Tests: Western NeuroSensory
Stimulation Profile (WNSSP)
• 113 point scale:
• great for showing incremental changes
• attn, generalized vs. localized responses
to stimulation, visual tracking, oral
reflexes
How to Assess Volitional vs.
Spontaneous Movement
• Structured observation
Compare:
– quiet environment
–vs. general stimulation
–vs. commands
• Change the order daily
• Same amount of time
Kentfield Structured Observation Chart
Rancho Los Amigos Cognitive Scale
-Revised
Level 4: Confused/Agitated:
Maximal Assistance
Behaviors:
• Alert and very motor restless
• Purposeful attempts to remove tubes,
crawl out of bed, etc.
• Fleeting attention with no memory or
control
May be receptive to basic non-language info
Rancho Los Amigos Cognitive Scale
-Revised
Level 4: Confused/Agitated: Max. Assist.
SLPs role
• Help them get through
• Tell and model to the family (and other
profs)
–Calm voice
–Body language
–Facial expression
–Re-assurance yet Treat them age
appropriately
Rancho Los Amigos Cognitive Scale
-Revised
Level 5: Confused, Inappropriate NonAgitated: Maximal Assistance
–Cognition is jumbled up
Functional Memory:
The Day Planner
Why?
– Improves Memory
– Improves reasoning
– Organization
– Landmarks of improvement
– Can address impulsivity
– Left neglect and reading and writing skills
– To live independently
The Day Planner
Schedule Section
• Page per day (already dated)
• Keep old pages: as a journal
• “Today” Book mark
The Day Planner
Therapy section
–Speech homework
–PT and OT
–Goals
The Day Planner
Personal Section
–Phone numbers
–Info from the doctor
–Journal
–Get well cards
–Whatever – it’s theirs!
The Day Planner
Paper Section
• Keep it blank!
The Day Planner
Concepts
–Ring binder, not spiral bound
–Pencil
–Keep it organized (daily)
–If you want a calendar page
–Habitualize it When should the pt. take
it with them?
–“Day Planner” vs. “Memory Book”
The Day Planner
• The Family’s role:
–Enter the schedule
–“What’s next?”
–“How are you going to remember
that?” not “Write that down”
Cognition
• Personally relevant
• Lists for generative naming, category
exclusion, sentence completion,
make a crossword puzzle
• Simple problem solving questions
Pragmatics
–Facial affect
• EACH facial feature
–Intonation
• “My new blue jacket”
–Social appropriateness
• For different (concrete) settings
Rancho Los Amigos Cognitive Scale
-Revised
Level 6: Confused, Appropriate,
Moderate Assistance…and beyond
Day Planner: Menu’s
1. Cognitive Tasks: answer email, plan
an outing, make a shopping list
2. Physical Tasks: shoot baskets, walk
on the beach, walk the mall
3. Household Chores: water house
plants, fold laundry, set table, feed
the dog, dust, sort the mail
4. Fun Activities: TV, play music, call a
friend, read: book, mag., newspaper
Executive Functioning
What executives do:
–Multi-task:
–Divide attention:
–Organize:
–Prioritize:
Executive Functioning
–See the big picture:
–See the details:
–Comprehend the consequences:
–Teach structures: “recipes”
Beyond Workbooks:
What does the patient need to
do? What do YOU do?
–Meal plan: menu/ Food list/
utensils-equipment
Meal Plan
MENU
Spag.
FOOD
*noodles
*oil
sauce
Parm. Chees
Salad
*lettuce
tomato
UTENSILS
noodle pan
sauce pan
colander
big spoon
bowl
cutting board
knife
etc…….
Beyond Workbooks:
What does the pt. need to do?
–Orchestrate a meal
–Transportation: bus
–Budget
–What to take to school
–Getting Assist. in stores
Beyond Workbooks:
What does the patient want?
•
•
•
•
Driver’s license
Date
Go to school
Have fun
Family
–Educate along the way
–Listen to them
–Model
• “I Statements” and model for them: “I
feel scared when you start walking in the
street without looking” not “YOU have
bad judgment”
Bottom line:
THEIR interest
=
YOUR therapeutic
success!