Pashek 022010 - c772064.r64.cf2.rackcdn.comc772064.r64.cf2.rackcdn.com/event/03700/03745/3745-sp-pashek-0… · PTSD symptoms in children with severe TBI than in children with moderate

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Welcome to this SpeechPathology.com Live Expert e-Seminar!

Mild Traumatic Brain Injury Update

Presented By:

Gail V. Pashek, Ph.D., CCC-SLP, Speech-Language Pathologist,

Kansas City Veterans Administration Medical Center

Moderated By:

Amy Hansen, M.A.,CCC-SLP, Managing Editor,

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Mild Traumatic Brain Mild Traumatic Brain Injury(mTBI): An UpdateInjury(mTBI): An Update

Gail V. Pashek, Ph. D., CCC-SLPKansas City Veterans Administration

Medical Center, Kansas City, [email protected]

DisclaimerDisclaimer

The opinions expressed in this presentation

and products endorsed reflect the views of

the author alone and not the official policy

of the Veterans Health Administration,

Department of Defense, or U.S.

Government.

Pashek, 2010

DefinitionDefinition

� “Mild Traumatic Brain Injury”◦ VA Guidelines – closely follow those provided by ◦ American Congress of Rehabilitation Medicine (1993) one or more of the following:� LOC <5 min� Any loss of memory for events before or after accident� Any alteration in mental state – up to 24h◦ Dazed◦ Confused◦ PTA

� Focal neurological deficits� Exclusion criteria:◦ LOC > 30 min.◦ PTA >24 h◦ Initial GCS less than 13

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Incidence of TBI/mild TBIIncidence of TBI/mild TBI

CDC Statistics� 1.4 million incidence/5.3 million prevalence� 75% considered “mild”McKinlay et al. 2008� 1 in 5 children will sustain a brain injury before age 16 of which 90% are judged to be “mild”

U. S. Government� 50% of all war-related injuries – TBI� 23% of all returning soldiers� 80% “mild

Pashek, 2010

“Mild” Traumatic Brain Injury“Mild” Traumatic Brain Injury

� Life disruption is not necessarily proportional to the “mildness” of injury as judged by a medical evaluation

� Doesn’t mean effects will be less dire on pt or family

� Pt’s awareness of problem often creates greater frustration than in more severe TBI

� “I don’t look any different, but I know I’m different.” People don’t understand.”

� Percussion effects of multiple blasts on the brain

Pashek, 2010

Blast InjuryBlast InjuryChanging the Face of Mild Traumatic Brain Injury

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Blast Injury (Explosive Blast Neurotrauma) Wallace, 2008

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Blast Injury in the MilitaryBlast Injury in the Military

� Increased incidence of TBI and mTBI in the Iraq and Afghanistan wars relative to previous wars◦ 80% of all war-related injuries are blast-related

◦ 40-50% involve traumatic brain injury

◦ High order explosives

� Susceptibility of military roles

� Increase in survival - improved protective equipment (body armor, Kevlar helmet)

Pashek, 2010

Blast Injury in the Military Blast Injury in the Military -- 22

U. S. Department of Defense (DOD) and Veterans Administration (VA)

• Population-wide screening for mTBI/concussion in the military• Upon return from deployment,• 3 to 6 months• Upon entering the VA for care

� Query: Did you experience a blast or explosion, vehicle accident, bullet wound, fall, or other injury event with:• Loss or alteration in consciousness? • Headache, difficulty sleeping, anxiety, • Number of incidents?• At what distance?

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Civilian CasualtiesCivilian Casualties

� Civilians are at risk during war, both children and adults

� Terrorism is increasingly affecting civilians◦ 2000-2003 70 suicide bombing attacks – Israel (Weil et al., 2007),

◦ Oklahoma City – Murrah Building 1995◦ Madrid train bombings 2004◦ London bus bombings 2005

� Other accidents involving explosions (e.g., gas leaks, fireworks accidents, etc.)

� Children more likely to develop head injuries than adults or adolescents

Pashek, 2010

Blast InjuriesBlast Injuries

� Direct Injuries – 4 levels defined◦ Primary (positive and negative blast wave)

◦ Secondary (projectiles hitting the body)

◦ Tertiary (the body as projectile)Quaternary (burns, crush injuries, injuries from toxic fumes)

� Indirect Injuries

Pashek, 2010

Primary Blast InjuryPrimary Blast Injury

� Primary Blast: Atmospheric over-pressure followed by under-pressure or vacuum; 1,000 mph◦ Skull displacement causing tension and pressure in the brain

◦ Contusions

◦ Diffuse Axonal Injury (DAI)

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Contusions Coup/Contrecoup

� Localized damage also

occurs when the brain bounces against the skull.

The brain stem, frontal

lobe, and temporal lobes are particularly

vulnerable to this because

of their location near bony protrusions inside the

skull.

Pashek, 2010


Vulnerable Areas

◦ Diffuse axonal injury (DAI) –hippocampus, amygdala, brain stem)

◦ Transfer of kinetic energy from blast wave to brain, causes DAI

◦ Cernak et al. - blast injury effects on rats� swellings of neurons, glial reaction, and myelin debris in the hippocampus

� Performance deficits within 3h

Axonal Injuries

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DAI Prone AreasDAI Prone Areas

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Secondary Blast EffectsSecondary Blast Effects

� Secondary Blast Effects

� Objects placed in motion by the blast hitting the service member

� Greatest risk of penetrating-head injury

� Shrapnel wounds

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Tertiary Blast EffectsTertiary Blast Effects

Tertiary Blast Effects

� Injury sustained when the body is placed in motion by the blast

� Contusions – coup and contrecoup injuries

� DAI

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Blast Injury Blast Injury –– Indirect Effects on Indirect Effects on the Brainthe Brain

Blast Injury & Polytrauma

◦ Overblast effects on organs feeding the brain

◦ Demonstrated hypoxiain myocardial depression without a compensatory vasoconstriction in research animals (Irwin et al., 1997)

Schematic – U. S. Army Medical Department

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Blast Injury Blast Injury -- PolytraumaPolytrauma

� High pressures lead to air-filled organ failure

� High frequency of vasospasms – early and late (Ling, Bandak, Armonda, Grant & Ecklund, 2009)

� Risk of pseudoaneurysm

�Multiple blasts - decreased threshold of internal organ injury (Yang et al. 1996)

Pashek, 2010

Blast Injury vs. Other TBI Blast Injury vs. Other TBI EtiologyEtiology

� Blast injury/sports injury – both have risk of repetitive injury◦ Sports – concern for Second Impact Syndrome◦ Military following of concussion guidelines? A complex issue

� Cognitive effects of multiple concussions –memory and attention (Moser, 2005; Guskiewicz, 2005 et al.)

� Yet, blast injury is more complex than sports concussion, given the over-pressure and under-pressure atmospheric dynamics and the quaternary collateral trauma.

Pashek, 2010

Many Issues Remain Re Military Many Issues Remain Re Military BlastBlast--related TBIsrelated TBIs

� Search continues for reliable biomarkers

� Present documentation is only self-report

� Criteria for removing soldiers from the field?

� Repetitive (percussive) injuries common

� There is little post-injury monitoring after a MTBI ◦ Limitations of self-report

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Military BlastMilitary Blast--Related TBIRelated TBI

“If you're talking about white, or even gray matter damage, it's often accompanied by loss of cognitive insight. If we're releasing these soldiers to the field with instructions to report any changes in their mental state, it probably won't happen because the person who suffers a mild brain injury is the least able to observe it in themselves. If a platoon leader sees them as filling a necessary niche and they appear to be doing well, they are not going to encourage them to report symptoms, either.”

(Graf man, as Cited in Samson, 2007)

Pashek, 2010

Complicating Factors in the Study and Complicating Factors in the Study and Treatment of Blast or Other mTBI Treatment of Blast or Other mTBI -- PCSPCS

Post-Concussive Syndrome

� Most individuals with mild TBI recover fairly well within 3-6 months post-injury

� 10-30% - chronic post-concussive symptoms.� Three categories of residual symptoms: ◦ Somatic (headache, tinnitus, sleep disorders etc.)◦ Cognitive(memory, attention and concentration difficulties

◦ Emotional/Behavioral(irritability, depression, anxiety, behavioral disorders) and at risk for other psychiatric disorders including:� Depression� Vulnerability to post-traumatic stress disorder (PTSD)

Pashek, 2010

Complicating Factors in the Study and Complicating Factors in the Study and Treatment of Blast or Other mTBI Treatment of Blast or Other mTBI -- PTSDPTSD

DSM-IV 309.81 Post Traumatic Stress DisorderPTSD Definition/Criteria:A. (1) The development of characteristic symptoms

following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity.

(2) The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

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Complicating Factors in the Study and Complicating Factors in the Study and Treatment of Blast or Other mTBI Treatment of Blast or Other mTBI –– PTSD PTSD

Additional DSM-IV criteria for PTSDB. The traumatic event is persistently re-

experienced.

C. There is avoidance of stimuli associated with the

trauma and numbing of general responsiveness.

D. There are persistent symptoms of increased

arousal

E. Duration of the disturbance (symptoms in Criteria

B, C, and D) is more than one month.

F. The disturbance causes clinically significant

distress or impairment in social, occupational, or

other important areas of functioning.

Pashek, 2010

Complicating Factors in the Study and Complicating Factors in the Study and Treatment of Blast or Other mTBI Treatment of Blast or Other mTBI –– PTSD PTSD

Additional Factors Affecting Cognition

� Potential Confounds of Alcohol and Substance Abuse

� Potential Confounds of Secondary Gain/Level of Effort

� Sleep Disorders

� Chronic Pain

Pashek, 2010

Possible Presenting DisordersPossible Presenting Disorders

� mTBI with Post Concussive Syndrome (PCS)

� mTBI without PCS

� mTBI with Post Traumatic Stress Disorder (PTSD)

� mTBI without PTSD

� mTBI with both PCS and PTSD

� PTSD without mTBI

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PTSD in TBI: ControversiesPTSD in TBI: Controversies

� It has been argued that PTSD cannot occur in amnestic patients, those with LOC or other severe BI symptoms (Mayou, Bryant, & Duthie)◦ Amnestic disturbance may not be complete, as described by King – “islands” of memory

� Levi et al. (1999) actually found higher rates of PTSD symptoms in children with severe TBI than in children with moderate TBI or orthopedic injuries

� Combat related PTSD can surface and remain many years post-trauma

� Autobiographical memory training may not be beneficial to individuals with PTSD

Pashek, 2010

CombatCombat--Related PTSDRelated PTSD

There is no “front” to the war as in previous conflicts

� Flashbacks

� Nightmares

� Hypervigilance

� Dissociation

� Persistence of symptoms for long periods of time

Pashek, 2010

Neuroimaging Developments in Neuroimaging Developments in mTBI mTBI (Image Source: bic.missouri.edu/images/whitemattertracking.jpg)(Image Source: bic.missouri.edu/images/whitemattertracking.jpg)

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Traditional Neuroimaging Methods and Traditional Neuroimaging Methods and the Pathophysiology of mTBIthe Pathophysiology of mTBI

� Common CT and MRI Structural Brain Images – no evidence of damage

� When neuroimaging findings are present –outcome is “complicated mild TBI” - outcome more similar to moderate TBI

� Pathophysiology in blast injury as well as other etiologies of mTBI◦ Injured cells exposed to extreme changes in intracellular/ extracellular chemical environments◦ Disequilibrium – cells are susceptible to changes in blood pressure, flow characteristics◦ Cytotoxic edema develops◦ Estimated duration > 2 weeks ◦ Not evident in gross structural analysis

Pashek, 2010

Diffusion Tensor ImagingDiffusion Tensor Imaging

� DAI affects primarily white matter of the brain

� Diffusion Tensor Imaging (DTI)◦ Sensitive to white matter changes in the exchange of intracellular and extracellular water diffusion in brain tissue

◦ Allows visualization of orientation and direction of white matter fiber tracts

DTI(Source: Wikipedia Commons)

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Diffusion Tensor Imaging Diffusion Tensor Imaging -- 22

� Diffusion Tensor Image◦ Diffusion MRI image

Results from the

statistical integration of displacement

distribution of water

molecules at a

microscopic level with

resolution in

millimeters

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Diffusion Tensor Imaging (Mayer, Diffusion Tensor Imaging (Mayer, 2010)2010)

DTI Differential Diagnostic Potential� 22 patients with semi-acute mTBI (x = 12 days po)

� 21 healthy matched controls with 3-5 mos. Po follow-up

� DTI differentially distinguished between normal brains and brains of individuals with TBI

� Detect changes both early and late post-injury (Mayer et al., 2010)

� However, the researchers also noted some normalization of white matter changes 3-5 mos. post initial imaging (Mayer et al. 2010)

Pashek, 2010

Summary Summary -- NeuroimagingNeuroimaging

� Summary◦ DTI Appears to be better diagnostic indicator of

mTBI than CT or common structural MRI

◦ Global white matter pathology as determined by

DTI negatively related to cognitive impairment in all

cognitive domains (Kraus et al.)

◦ DTI changes noted over time may make it a neurological marker of mTBI recovery than clinical

imaging with MRI or CT

◦ More longitudinal studies needed (e.g., problem of

Dx in military)

Pashek, 2010

Neuroimaging Neuroimaging -- mTBImTBI

Other neuroimaging methods being explored demonstrating potential:

� Magnetic Resonance Susceptibility Weighted Imaging (MR-SWI)◦ “susceptibility” – degree of magnetization of a material in a magnetic field◦ good at detecting “microbleeds” (<5mm) common in DAI– venous blood and iron storage

� Magnetic Resonance Spectroscopy –allows non-invasive biochemical analysis of brain tissue for specific compounds (e.g., N-acetylaspartate, glutamate)

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Issues in Neuroimaging of Issues in Neuroimaging of mTBI/Blast InjurymTBI/Blast Injury

◦Can mTBI and PTSD be distinguished on the basis of neuroimaging results?

◦Can neuroimaging predict who will develop post-concussive syndrome?

Pashek, 2010

Neurobehavioral Assessment of Neurobehavioral Assessment of Mild Traumatic Brain InjuryMild Traumatic Brain Injury

Pashek, 2010

Forms of Neurobehavioral Forms of Neurobehavioral AssessmentsAssessments

Forms of Neurobehavioral Assessments

1. Neuropsychological

2. Cognitive Rehabilitation

� Necessary

� Complementary

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Two Forms of EvaluationTwo Forms of Evaluation

Neuropsychologic Evaluation

Cognitive Rehabilitation Evaluation

◦ Documents deficits; used for forensic/legal purposes

◦ “Static” snapshots of functioning (Parente, 2003)

◦ Focused on “product” of performance

◦ Loosely correlated to brain structure

◦ Assesses constructs of “intelligence” and psychopathology

◦ More didactic, diagnostic

◦ Projects functional abilities – construct validity

� Focuses on retained abilities as well as deficits

� Dynamic picture of functioning

� Focused on “process” of performance

� Focus on learning potential and characteristics

� More pragmatic, prognostic� Assesses functional abilitiesin meaningful contexts –ecological validity

Pashek, 2010

Military mTBI PatientMilitary mTBI Patient

� Prototypical mTBI patient seen in our clinic◦ Exposure - multiple blasts◦ Often no LOC - dazed or disoriented◦ Good verbal skills in interview◦ Memory, concentration complaints◦ PCS symptoms – headache, insomnia, tinnitus, irritable, depressed◦ PTSD – hypervigilant, isolationist, possibly fearful, non-emotive◦ Generally, very aware of deficits

Pashek, 2010

Components of a ProblemComponents of a Problem--Focused Focused Cognitive Rehabilitation EvaluationCognitive Rehabilitation Evaluation

� Chart review – emphasizing psychiatric, psychological, educational, and vocational notes

� Medication review

� Structured Interview – with pt and other who knows the pt well; key components:

� Cognitive Questionnaires

� Brief Technology Questionnaire (e.g., Gillette, DePompei & Goetz, 2009)P

� Direct Testing

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ANCDS Practice Guidelines for Assessment available at www.ANCDS.org

1) Turkstra, L., Ylvisaker, M., Coelho, C., Kennedy, M., Sohlberg, M. M., & Avery, J. (2005). Practice guidelines for standardized assessment for persons with traumatic brain injury. Journal of Medical Speech-Language Pathology, 13(2).

� Detailed psychometric analyses of and expert commentary on measures commonly administered by speech-language pathologists.

also,

2) Coelho, C., Ylvisaker, M., & Turkstra, L. (2005). Nonstandardized assessment approaches for individuals with traumatic brain injuries. Seminars in Speech & Language. 26(4):223-41

Pashek, 2010

Selection of Formal MeasuresSelection of Formal Measures

Traditional SLP-oriented TBI measures are usually insufficient to pick up deficits described by mTBI patients:

� Brief Test of Head Injury (BTHI; Helm-Estabrooks, 1991)� Scales of Cognitive Ability for Traumatic Head Injury (SCATBI; Adamovich & Henderson, 1992)

� Cognitive Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001)

� Burns Brief Inventory of Communication and Cognition (Burns, 1997)

� Ross Information Processing Assessment (RIPA-2; Ross-Swain, 1996)

Pashek, 2010

SemiSemi--structured Cognitivestructured Cognitive--Plus Plus InterviewInterview

◦ Goals of patient, AND significant other◦ Self-described problems◦ Questionnaires – skills in context◦ “Systems” Review

� Perception� Speech� Language� Attention� Memory – recent, remote, event, prospective� Executive Functions� Speed of Processing

◦ Plus questions regarding:� Learning Style� Sleep� “Average” day

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Highlighted MeasuresEspecially suitable for MTBI

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Evaluation MeasuresEvaluation Measures

Standardized Questionnaire –administered both to patient and significant other◦ Frontal Systems Behavioral Scale (FrSBe; Grace & Malloy, 2001 ) – 3 areas of frontal lobe functioning

� “Apathy”

� “Disinhibition”

� “Executive Functions”

◦ Pre- and Post-injury (deployment) ratings

◦ Observe how patient completes the measures

Pashek, 2010

Measure Selection and Analysis: Measure Selection and Analysis: Author’s Preferred MeasuresAuthor’s Preferred Measures

◦ Memory◦ California Verbal Learning Test (CVLT-II; Delis, Kramer, Kaplan & Ober, ) – verbal list learning◦ Improvement over repeated trials◦ Recall vs. recognition memory◦ Organization recall characteristicsRole of interference – proactive, retroactive◦ Delayed memory

◦ Copy, immediate recall, and delayed recall of the Rey-Osterrith Complex Figure � Perceptual/constructional ability

� Visual memory

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Measure Selection and AnalysisMeasure Selection and Analysis

Executive Functions/Everyday Problem Solving

Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; McDonald, 2005) “standardized test of subtle cognitive-communicative difficulties designed specifically for those with acquired brain injuries…[and which] is designed to detect deficits which may not be apparent on typical standardized tasks” (p. 1)

� Targeted skills – complex comprehension/expression, verbal reasoning, executive functions

� Author notes that a number of deficits may not become apparent until the cognitive load reflects the complexities of daily living situations

� Ecological validity

Pashek, 2010


A. FAVRES 4 tasks

1. Scheduling an event

2. Scheduling

3. Making a decision

4. Building a case

� Can administer and interpret individual tasks, although analysis across tasks is recommended

Pashek, 2010


FAVRES Scoring System

Points Basis of Score

5 Answer choice accounts for all facts mentioned in question

4 Answer choice accounts for more than half of the facts in the question

3 Answer choice accounts for more than half of the facts in the question

2 Answer choice accounts for less than half of the facts in the question

1 Answer choice reflects an inaccurate attempt to consider one fact

0 Answer choice is entirely inaccurate, inappropriate, or no answer given

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FAVRES Summary SkillsFAVRES Summary Skills

Interpreting Scores Within and Across Tasks1. Normal Cut Off scores

2. Accuracy and Rationale Percentiles/SS

3. Time Percentiles/SS

4. Reasoning Subskillsa. Getting the facts

b. Eliminating irrelevant information

c. Weighing facts

d. Flexibility

e. Generating alternatives

f. Predicting consequences

g. Total reasoning subskills

Pashek, 2010

Repeatable Battery of Repeatable Battery of Neuropsychological StatusNeuropsychological Status

Commentary: Repeatable Battery of Neuropsychological Status (RBANS)

� Commonly used by neuropsychologists and now speech-language pathologists

� Good psychometric properties� However, the RBANs is a screening tool that is oriented more toward documentation of an impairment than a therapy evaluation◦ Does not allow for analysis of strategies as other tests (e.g., CVLT) do, e.g., organizational strategies in list learning

◦ Language portion is generally too easy to pick up subtle deficits or strategies

◦ Measures of attention (digit span, symbol digit task) do not get at higher level attention disorders, such as divided attention, distractibility

Pashek, 2010

Blast Injury Assessment ProfilesBlast Injury Assessment Profiles

� Anecdotal/Surprising Findings in Assessment of Blast Injury Patients with Blast Injury/Mild TBI by This Author◦ Extremely mild, often subclinical deficits

◦ Cognitive deficits apparent in testing in PTSD only cases

◦ Autobiographical memory/remote memory loss without retrograde amnesia in some individuals (if PTSD, working on autobiographical memory may not be recommended)

◦ Slowing of cognitive performance, in some instances comparable to that in older adults

◦ Varied divided attention deficits; vigilance often is quite good

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Cognitive Rehabilitation Treatment: Mild TBI

Focus on Executive Functions

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Request for ReferralRequest for Referral

“Cognitive/language (or cognitive rehabilitation) evaluation and treat as indicated”

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Approaches to mTBI adultsGreatest face validity and strongest efficacy data

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Restoration vs. CompensationA Useful Controversy?

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“Restorative” Approach“Restorative” Approach

� Restorative Approach Perspective◦ Restorative Treatments (Coltheart – “Cognitivist Approach”– Based on model of the cognitive process and deficit and of neurological recovery mechanisms

◦ Focus on “experience driven plasticity”

◦ Cognitivists argue that compensatory approaches are atheoretical

◦ Approaches assume that teaching compensatory strategies may negatively affect potential for restoration of function (largely based on results of selected animal studies)

The jury is still out…

Pashek, 2010

“Compensatory” Approaches“Compensatory” Approaches

� Cognitive Prostheses◦ PDAs◦ Memory Books◦ Recorders◦ Medication Organizers

� Environmental Compensation◦ Family prompts◦ Labeling of the environment, etc.

� Internal Strategies◦ Word Substitution◦ Asking for help, etc.

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Can Some “Compensatory” Can Some “Compensatory” Strategies Facilitate Restoration? Strategies Facilitate Restoration?

Some “compensatory” approaches appear have some degree of restorative potential in some individuals, e.g.:◦ Circumlocution

◦ Use of imagery

◦ Self-talk to organize action

◦ “Re-organization Approaches e.g., “Gestural facilitation of speech,” “Treatment of Aphasic Perseveration” etc.

Pashek, 2010

Compensatory Approaches are Compensatory Approaches are Necessary Necessary

Compensatory Approaches� Pragmatically driven◦ Rehabilitation Funding◦ Early success◦ Functional need◦ Lack of strong neuropsychological models for many cognitive processes/deficits◦ Lack of evidence of detrimental effects in humans◦ Fairly strong evidence base for some interventions

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Use of Cognitive Prosthesis – External AidsAn Expanding Field

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Cognitive Prostheses Cognitive Prostheses –– Meeting Meeting Immediate Functional NeedsImmediate Functional Needs

ANCDS Practice Guidelines for Treatment available at www.ANCDS.org

Sohlberg, M. M., Kennedy, M. R. T., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence based practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech Pathology, 15 (1).

Pashek, 2010


General Cognitive Aids� Medication organizers with/without alarms� Alarm watches� Smartphones, PDAs and written planners◦ Appointments, medications, memos

◦ Customizable applications (e.g., bank reminder for bill paying) our goal is to have the client “glue” their PDA to them

� Devices with GPS capability◦ Topographical orientation disorder

◦ Also useful for attention deficits in drivers

Pashek, 2010


Academic cognitive aids◦ Digital recorders◦ “Smart” pens◦ Cognitive prostheses to aid with time management

Consideration:The devices themselves are not the therapy; training appropriate and expansive use of these aids IS

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Training Executive Functions, Memory, and Attention – Facilitating Organized, Goal Directed Thinking and Strategies

Pashek, 2010

Kennedy et al., 2005Kennedy et al., 2005

Treatment of Executive Functions - Self Management and Regulation

“Converging evidence from educational,cognitive, and neuropsychologicalrehabilitation indicates that self-regulationis represented as the dynamic relationships among metacognitive beliefs and knowledge, self-monitoring and self-controlduring activities, and strategy use.”

(p. 252)

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Treatment of Executive FunctionsTreatment of Executive Functions

Focus on Self Management and Self Regulation

� Goal Setting and Goal Management

� Problem Solving

� Awareness and Metacognitive Strategy Training

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Goal Oriented TherapiesGoal Oriented Therapies

� Strong ecological validity

� Necessarily involve patient in treatment process

� Particularly well-suited to individuals at transitional points in life

� Based on self-regulation theory (see McPherson et al., 2009)

� Several approaches to be discussed:◦ Goal Setting Guide (Pashek, unpublished)

◦ Identity Oriented Goal Training (Ylvisaker & Feeney, 2000)

◦ Goal Management Training (Levine & Robertson, 2000)

Pashek, 2010

Treatment of Executive FunctionsTreatment of Executive Functions

ANCDS Practice Guidelines for Treatment available at www.ANCDS.org

� Kennedy, M. R. T. & Coelho, C. (2005). Self-regulation

after traumatic brain injury: A framework for

intervention of memory and problem solving.

Seminars in Speech and Language, 26, 242-255.

� Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker,

M., Sohlberg, M. M., Yorkston, K., Chiou, H. H. & Kan,

P. F. (2008). Intervention for executive functions after

traumatic brain injury: A systematic review, meta-

analysis and clinical recommendations. Neuropsychological Rehabilitation, 18 (3), 257-299 .

Pashek, 2010

Goal Development TreatmentsGoal Development Treatments

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Initial Goal Setting Guide: Sample Initial Goal Setting Guide: Sample 1 1 (Pashek, unpublished)(Pashek, unpublished)

Goal Setting Guide◦ Identify a Goal (graphic organizer)

Provide Aids (if needed)� What goals have you achieved in the past?

� Why were they important?

� Identify potential areas – (personal, work, spiritual, recreational, etc.)

� What is important to you now?

◦What steps do you need to do to achieve this goal?◦What might get in the way of achieving this goal?

Pashek, 2010

Initial Goal Setting Guide: Sample Initial Goal Setting Guide: Sample 2 2 (Ylvisaker et al., 2009)(Ylvisaker et al., 2009)

Identity Oriented Goal Training (IODT) Six-step questioning process:

� Who is someone you admire?

� Identify characteristics of the person?

� What characteristics do they have? (facts, appearance)

� What goals did s/he have?

� Identify goal and feeling achieving the goal would give.

Pashek, 2010

Identity Oriented Goal TrainingIdentity Oriented Goal Training

Goal Management Training

(Levine & Robertson, 2000)

� Best researched method

� Focused on decreasing the possibility of failure

STOP What am I doing?

DEFINE The main task

LIST The steps

LEARN The steps

TEST Do I know the steps?

DO IT

CHECK Am I doing what I planned)

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Goal Attainment Scaling (GAS) A Goal Attainment Scaling (GAS) A Method for Quantifying ProgressMethod for Quantifying Progress

Goal 1 Goal 2 Goal 3

Review Date

Much more than expected

(+2)

More than expected (+1)

As expected(0)

Less than expected (-1)

Much less than expected (-2)

Pashek, 2010

� Self-management strategies recommended in attention and memory training as well from evidence-based reviews using a variety of treatment approaches

� Attention - Sohlberg, Avery, Kennedy et al. (2003).

� Memory - Erlhardt, Sohlberg, Kennedy et al. (2008).

Pashek, 2010

Advantages to GASAdvantages to GAS

� Is patient driven, to the extent possible� Attaches a measure to often difficult-to-quantify goals

� Promotes organized thinking and metacognitive skills

� Accommodates multiple rehabilitation goals in one measure

� Provides focus to treatment and for patients with attention/memory problems

� Assists in overall treatment management, discharge planning

� Is potentially generalizable(McPherson, Kayes, & Weatherall, 2009)

Pashek, 2010

2/19/2010

Pashek, 2010 29

Goal setting for Military PatientsGoal setting for Military Patients

� Especially helpful in assisting young service members who◦ Understood the concept of goal (“mission”) in the context of their service

◦ Must totally revise goals with medical discharge

◦ Were never particularly goal-oriented to begin with

◦ Are at a point in life when goal-setting becomes particularly important

Pashek, 2010

The Need to Know Why…The Need to Know Why…

� Meta-analyses tell us what works and how well it works

� There remains a need to know WHY such strategies are effective

� Speculation:◦ Critical role of central executive in all activities?◦ Training of a generalized organized thinking process?◦ Strength of multimodal training?◦ “Top-down” strategy, rather than incremental bottom-up?◦ Real life, functional significance for client?◦ Increasing self-awareness?

Pashek, 2010

Future Directions/NeedsFuture Directions/Needs

� Does cognition in mTBI vary as a function of etiology?

� How much overlap is there between mTBI and PTSD in cognitive impairments?

� Are pharmaceutical agents effective in remediation of cognition in mTBI and PTSD?

� How can virtual reality be employed in cognitive rehabilitation?

Pashek, 2010