ManagementofseveretraumaticbraininjuryLAURAWILSON,PHD,CCC-SLP, CBIST

9/27/19

DisclosuresIamafull-timeemployeeatTheUniversityofTulsa

KSHAisprovidinganhonorariumformyparticipationtoday

IamaCertifiedBrainInjurySpecialistTrainerthroughtheACBIS/BIAA

Nootherfinancialornon-financialrelationshipstodisclose

LearningObjectives1. Describemedical,neurobehavioral,andpsychosocialfactorsthatcanimpactinterventionin

individualswithseveretraumaticbraininjury

2. Identifyappropriateassessmenttoolstohelpguidetreatmentofcognitive-communicativesequelaeaftersevereTBI

3. Summarizetheevidence-basedtreatmentapproachesusedtoaddresscognitive-communicativesequelaeofseveretraumaticbraininjury

WhatdowemeanbysevereTBI?

RecreatedfromtheVA/DODClinicalPracticeGuidelinefortheManagementofConcussion-MildTraumaticBrainInjury;TheManagementofConcussion-mildTraumaticBrainInjuryWorkingGroup,2016

Concussion mTBI

Criteria Mild Moderate Severe

Structuralimaging

Normal Normalorabnormal

Normalorabnormal

LOC Upto30minutes 30 minutesupto24hours

24hoursormore

AOC Up to24hours >24hours >24hours

PTA 0-1 day Between 1-7days

>7days

GCS 13-15 9-12 3-8

TBIOutcomesChroniccondition

Increasedmorbidityandmortality

Frequentcomorbidities

Complicatedcontinuumofcare

Persistentcognitive,physical,psychosocialdeficits

Behavioralandpsychosocialcomplications/comorbiditiesBEHAVIORAL

Aggression

Agitation/irritability

Apathy

Denialofdeficitsand/oranosognosia

Disinhibition

Eatingdisturbances

PSYCHOSOCIAL

Depression

Anxiety

Substanceabuse

Otherpsychiatricdisorders

Socialisolation/reducedsocialnetwork

Caregiverburden

Reductioninparticipation

Flataffect/inabilitytorecognizeemotions

Impulsivity

Lability

Poorinitiation

Poorjudgmentandreasoning

Kolakowsky-Hayner,Reyst,&Abashian,2016

Continuumofcare?Determinedby…

• Fundingsource

• Bedavailability

• Abilitytoparticipate intherapy

• Medicalneeds

• Challengingbehaviors

• Supportsystem

Principlesofassessmentandtreatment

WHO’sICF:Implicationsforassessment

Environmentalandpersonalfactors?Medicalstatus,includinghistoryofbraininjury

Premorbidcognitive-linguisticskills

Education,occupation,socioeconomic,cultural,andlinguisticbackground

Auditory,visual,motor,cognitive(e.g.,arousal),emotional,behavioralstatus

Reviewofauditory,visual,motor,cognitive,andemotionalstatus.

Clientandfamilygoalsandconcerns

ASHAPracticePortal

MoreconsiderationsforassessmentPeriodic,ongoingassessment

Usedirectreportfromfamilyandpatients,naturalisticobservation,andperformance-basedmeasures

Includetestswithgoodecologicalvalidity

Usedynamicassessmentandhypothesistesting

ASHAPracticePortal;Coehloetal.,2005

Treatmentprinciples✓Shaping✓Gradedcueing(pushforself-monitoring)✓Distributedpractice✓Errorlesslearning✓Remediationv.compensation

✓InterventionMUSTincludeintentionalgeneralization✓Functionalinterventions✓Familyinvolvement✓Assistivetechnologyforcognition✓Limitedevidencefortransferacrosscognitivedomains

Sohlberg &Mateer,2001

TimingofIntervention- earlyworks!Earlyandaggressivemultidisciplinaryneurorehabilitation◦ Shorterlengthofcoma◦ Shorterlengthofstayintrauma/rehab◦ HigherRanchoscores,lessimpairment◦ Greaterratesofreturntohome

Systematicearlyorientationprogram◦ LongerPTA,betterGOSEoutcomeat12months

Earlymultisensorystimulation◦ 75minutesperday,14days◦ Betterfunctionaloutcome(GOSE,DRS)at12months)

Earlymultisensorystimulationforpatients inacoma◦ Family-deliveredstimulation(30minutesperday)ledtohigherlevelsofconsciousnesswithinthefirstweek

◦ Therapist-deliveredstimulation(100minutesperday)ledtohigherlevelsofconsciousness

◦ Nursev.familydeliveredstimulation(80minutesperday)- family-deliveredledtohigherlevelofconsciousness,basiccognitivefunctioning,andsensoryfunctioning.

Königsetal.,2018

IntensityofIntervention- morecanfacilitaterecoveryGreatertimemaybeassociatedwith…◦ Improvedself-care,continence,mobility transfers,locomotion, communication, psychosocialfunctioning, andcognitionatdischargefromrehabilitation

◦ Greaterlikelihood ofreturn toworkat24months◦ Bettercommunity integrationafter16weeks(20v.15hoursoftherapy)

ButmightbeanincreaseinRATEv.extentofrecovery(somedifferencesexistonlyinfirstfewmonths)

Königsetal.,2018

PharmacologicalmanagementofsevereTBI◦ Fluidandelectrolytemanagement◦ Osmoticdiuretic◦ Paincontrolandsedation◦ Pentobarbitalcoma◦ Seizureprophylaxis◦ Neuromuscularblockingagents◦ Antithrombotic agents◦ Antimicrobialagents◦ Stressulcerprophylaxis

RoleoftheSLP◦ Observeanddocumentadverseeffects(e.g.,decreasedarousal)

◦ Communicateanyobservedstatuschanges(e.g.,increaseinfrequencyofseizures)

◦ Providecognitivetrainingrelatedtomedicationmanagement

Rivera,2014

RanchoLosAmigosLevelsofCognitiveFunctioningScaleLevel1 NoResponseLevel2 GeneralizedResponse

Level3 LocalizedResponse

Level4 Confused-Agitated

Level5 Confused-Inappropriate

Level 6 Confused-Appropriate

Level7 Automatic-Appropriate

Level8 Purposeful-Appropriate

Keytoolforfamilyeducation◦ https://sunnybrook.ca/uploads/1/programs/trauma-emergency-care/rancho-los-amigos-scale-of-cognitive-recovery-acc.pdf

Guidesgeneraltreatmentgoals◦ Stimulate◦ Structure◦ Compensate/Remediate

Sander,2002

AssessmentofdisordersofconsciousnessStandardizedassessmentsshouldbeusedforserialassessment

e.g.,ComaRecoveryScale–Revised(CRS-R),looksatauditory,visual,motor,orometer/verbal,communication,arousal

SignsofemergingconsciousnessVisualtracking,non-stereotypicmotorresponses,emotionalresponses

SpauldingRehabilitationNetworkisanexcellent sourceofresources!

FromLaureys,Owen,&Schiff,2004

Giacino,etal.,2018

Persistent,thenchronicv.permanentvegetativestate

TreatmentprinciplesforDOCMultisensorystimulation

Environmentalmanagement

Familyeducationandinclusion

Klingshirn etal.,2015

AfteremergencefromcomaFocusoninformal,functionalassessmentofskills

Trackamnesia,orientation,andattention

Monitorqualityoflanguageoutput,self-awareness

Engageindesiredactivities

Decreasetaskdemandsandattentionalload

Addressbehaviorthroughenvironmentalchangeandredirectionv.confrontation

Developconsistentroutines(whichrequiresfamilytraining!)

Monitorownrateandcomplexitywhenprovidinginformation/requestinginformation

Externalaidsmaybeuseful,butwillrequireextensivesupportfromtherapist-staff-family

Afterbehaviorbecomesappropriate…RLASVI ANDBEYOND

AssessmentREADYFORFORMALASSESSMENT?

✓Needstobeabletosustainattention✓Needstobeabletoofferareliableresponse✓Needstonotbeextremelyconfusedoragitated

IMPORTANTTAKE-AWAYS

Scoresnotasasimportantaswhatyouobserveduringtheassessment◦ Useofstrategies(spontaneous andprompted)◦ Responsetocues◦ Frustrationtolerance,fatigue◦ Ability tofollowinstructions, attendtotask

Attentionassessment◦ Examplesofformalassessment◦ RatingScale:MossAttentionRatingScale◦ Battery:TestofEverydayAttention

◦ BUT…challengingwiththispopulation

◦ Additional tasksforassessment◦ Forwarddigitspan◦ Digitsymbol coding◦ TrailMakingTest◦ Conners’ CPT◦ PASAT

Attentiontreatment◦ Metacognitivestrategytraining

◦ Moreevidenceformild-mod,butsomesmallstudiesthatshowbenefitintheseverepopulation

◦ Moredetailonthespecifics ofMSTintalklatertodayonexecutivefunction

◦ Dualtasktraining◦ Focusonindividualtasksfirst◦ Then, incorporatesimultaneousperformance◦ DoNOTexpectdistantgeneralization

◦ Addresscomorbidissuesthroughreferral◦ Depression,pain,sleep

◦ Environmentalsupports/modifications◦ Pacing,reducingdistractors◦ UsingATC

◦ Computerizedattentiontraining(?)◦ Ifused,considercompensationasremediationasthemechanism

◦ Cognitivebehavioraltherapy(?)

Ponsfordetal.,2014

MemoryassessmentCommonsampletools:

WechslerMemoryScale

RivermeadBehaviouralMemoryTest

CaliforniaVerbalLearningTest

MemoryforIntentionsTest

Considerthetypeofmemorythatyouareassessing:◦ Encoding◦ Retentionofinformation◦ Recognition

Rememberthatmemoryreliesonattentionandexecutiveskills!

Remembertowatchforpatterns:◦ Primacyv.recency◦ Verbalv.nonverbal◦ Semanticv.episodic

Velikonja, etal.,2014

MemorytreatmentFocusisonCOMPENSATION,andnotremediation

Internalcompensatorystrategies◦ Awarenessandintentionaddedtotheencodingphaseofmemory◦ Reliesonthosewithrelativelyintactexecutivefunctionskills◦ Oftenunsuccessfulforthosewithamoreseveredisorder

Externalcompensatorystrategies◦ Environmentalsupportsandreminders◦ Mustconsiderpreferences/premorbidexperienceswithsimilardevices,othercomorbidities

◦ TRAINtheuseofthesestrategies◦ Distributedpractice◦ Multipleexemplars◦ Don’texpect generalizationtooccur◦ Useerrorlesslearning,spacedretrieval

Velikonja, etal.,2014

NOTE:Spacedretrievalcanbesuccessfulinlearningspecificinformation(butnotwithgenerallyimprovingmemory)!

EXECUTIVEFUNCTIONWewillexplore thisindepththisafternoon.

Specifically forsevereTBI:

• Getreportfromfamilyandpatient(e.g.,BRIEF-A)

• Considerhowawarenesswillhaveimpactonotherinterventions

• Heavier reliance onexternal cuesandATCascomparedtometacognitive interventions

Cognitive-communicationASSESSMENT

Weknowthatthesedeficitscanhavewidespreadeffectsonanindividualpost-onset

Weknowthatcog-commskillscanbesituationally dependent!

Largelyinformalassessment◦ Monologicandconversationaldiscourse

Ratingscaleexample:◦ LaTrobe CommunicationQuestionnaire

◦ Conversationaltone,effectiveness, flow,engagement, partnersensitivity,andconversationalattention/focus

◦ Bothselfandother-report

TREATMENT

◦ Common featuresofgood interventions◦ Individualized,meaningful goals◦ Instructionalmethods thatareappropriate◦ Planned generalization◦ Communicationpartnerinclusion◦ Measuringfunctional outcomes

◦ Group trainingcanbebeneficial

◦ Samplecurriculum◦ TBIConnect/TBIexpress◦ Togheretal.,2013;Togheretal.,2016

Togheretal.,2014;Steel&Togher, 2019;Coehloetal.,2005

BehavioralconcernsDueto….

“Preinjuryadjustmentproblems

Impairmentstieddirectlytotheinjury

Post-injuryevolutionofsymptomsandadjustment

Poorlyconceivedinterventions(e.g.,overlyrestrictivesettingsandproceduresagainstwhichindividualsmaychoosetoreact)”

Commoninterventionstrategies:◦ ABA◦ PBIS◦ CBT

Feeney,2010,p.146

Positivebehaviorinterventionsandsupports:Principles1. Thepersonisthecoreofallinterventionandsupportefforts2. Interventionsandsupportsareorganizedaroundpersonallymeaningfulactivities3. Contextualsupportsarecriticaltosuccess4. Reductionofsupportsispartoftheplan5. Positiveeverydayroutinesarethecontextforpursuitofmeaningfulgoals6. Componentsoflifemustbeintegrated7. Assessment isongoingandcontext-sensitive8. Feedbackmustbecontext-sensitive andmeaningful9. Behavioralsupportsarepositiveandproactive10. Theultimategoalforparticipants iseffectiveself-regulationwithinameaningfullife

Feeney,2010,p.147-148

OtherconsiderationsGlasgowOutcomeScale-Extended

DisabilityRatingScale

Mayo-PortlandAdaptabilityInventory

CommunityIntegrationQuestionnaire

CraigHandicapAssessmentandReportingTechnique(SF)

QOLIBRI

Manyavailablehere:http://tbims.org/combi/list.html

Addressfamilyconcerns◦ Familyneedsquestionnaire◦ Support groupsandresources◦ https://www.biausa.org/

◦ http://biaks.org/◦ https://msktc.org/tbi◦ https://usbia.org/◦ https://www.kdads.ks.gov/commissions/home-community-

based-services-(hcbs)/programs/tramatic-brain-injury◦ http://www.mindsmatterllc.com/

Addressreturntoemploymentandleisureactivities

ReferencesAmericanSpeech-Language-Hearing Association.(2019).TraumaticBrainInjuryinAdults.Accessedathttps://www.asha.org/Practice-Portal/Clinical-Topics/Traumatic-Brain-Injury-in-Adults/.

Coelho,C.,Ylvisaker,M.,&Turkstra,L.S.(2005).Nonstandardizedassessmentapproachesforindividualswithtraumaticbraininjuries.SeminarsinSpeechandLanguage,26(4),223-241.

Feeney, T.J.(2010).there’salwayssomethingthatworks:Principlesandpracticesofpositivesupportforindividualswithtraumaticbraininjuryandproblembehaviors.SeminarsinSpeechandLanguage,31(3),145-161.

Giacino,J.T.,Katz,D.I.,Schiff,N.D.,Whyte,J.Ashman,E.J.,Ashwal,S.,Barbano,R.,Hammond,F.M.,Laureys,S.Ling,G.S.F.,Nakase-Richardson,R.Seel,R.T.,Yablon,S.,Getchius,T.S.D.,Gronseth,G.S.,&Armstrong,M.J.(2018).Practiceguidelineupdaterecommendationssummary:Disordersofconsciousness.Neurology,91,450-460.

Klingshirn,H.,Grill,E.,Bender,A.,Strobl,R.,Mittrach,R.,Braitmayer,K.,&Müller,M.(2015).Qualityofevidenceofrehabilitationinterventionsinlong- termcareforpeoplewithseveredisordersofconsciousnessafterbraininjury:Asystematicreview.JournalofRehabilitationMedicine,45,577-585.

Kolakowsky-Hayner,S.A.,Reyst,H.,&Abashian,M.C.(Eds.)(2016).TheEssentialBrainInjuryGuide,5th Ed.Vienna,VA:BrainInjuryAssociationofAmerica.

Königs,M.,Beurskens,E.A.,Snoep,L.,Scherder,E.J.,&Oosterlaan,J.(2018).Effectsoftimingandintensityofneurorehabilitationonfunctionaloutcomeaftertraumaticbraininjury:Asystematicreviewandmeta-analysis.ArchivesofPhysicalMedicineandRehabilitation,99,1149-59

Laureys,S.,Owen,A.M.,&Schiff,N.D.(2004).Brainfunctionincoma,vegetativestate,andrelateddisorders.LancetNeurology,3(9),537-546.

TheManagement ofConcussion-mildTraumaticBrainInjuryWorkingGroup.(2016).VA/DoDclinicalpracticeguidelineforthemanagementofconcussion-mildtraumaticbraininjury,2.0.Accessedathttps://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf.

ReferencesPonsford,J.,Bayley,M.,Wiseman-Hakes, C.,Togher,L.,Velikonja,D.,McIntyre,A.,Janzen,S.,&Tate,R.(2014).INCOGrecommendations formanagement ofcognitionfollowingtraumaticbraininjury,partII:Attentionandinformationprocessingspeed.JournalofHeadTraumaRehabilitation,29(4),321-337.

Rivera,J.O.(2014).Pharmacologicalmanagement oftraumaticbraininjuryandimplicationsforspeech languagepathology.SeminarsinSpeechandLanguage,35(3),196-203.

Sander,A.(2002).TheLevel ofCognitiveFunctioningScale. TheCenterforOutcomeMeasurement inBrainInjury.http://www.tbims.org/combi/lcfs(accessed August20,2019).

Sohlberg,M.M.,&Mateer,C.A.(2001).Cognitiverehabilitation:AnIntegrativeNeuropsychologicalApproach (2nd ed).NewYork:GuilfordPress.

Steel,J.&Togher,L.(2018).Socialcommunicationassessment afterTBI:Anarrativereviewofinnovationsinpragmaticanddiscourseassessmentmethods,BrainInjury,33(1),48-61.

Togher,L.,McDonald,S.,Tate,R.,Power,E.,&Rietdijk,R.(2013).Trainingcommunicationpartnersofpeoplewithseveretraumaticbraininjuryimproveseverydayconversations:Amulticenter singleblindclinicaltrial.JournalofRehabilitationMedicine,45,637-645.

Togher,L.,Wiseman-Hakes, C.,Douglas,J.,Stergiou-Kita,M.,Ponsford,J.,Teasell, R.,Bayley,M.,&Turkstra,L.(2014).INCOGrecommendations formanagement ofcognitionfollowingtraumaticbraininjury,partIV:Cognitivecommunication. JournalofHeadTraumaRehabilitation,29(4),353-368.

Togher,L.,McDonald,S.,Tate,R.,Rietdijk,R.,&Power,E.(2016).Theeffectiveness ofsocialcommunication partnertraining foradultswithseverechronicTBIandtheirfamiliesusingameasureofperceivedcommunicationability.NeuroRehabilitation,38, 243-255.

Velikonja,D.,Tate, R.,Ponsford,J.,McIntyre,A.,Janzen,S.,&Bayley,M.(2014).INCOGrecommendations formanagement of cognitionfollowingtraumaticbraininjury,partV:Memory.JournalofHeadTraumaRehabilitation,29(4),369-386.