The Patient Centered Team - NCSHLA€¦ · Members (SM) following mild traumatic brain injury (mTBI)/concussion. The general mission, staffing, goals, patient population, and discipline-specific

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Intrepid Spirit

Concussion Recovery

Center (ISCRC)

THE PATIENT CENTERED TEAM: HOW AND INTERDISCIPLINARY APPROACH IS USED WITH SERVICE MEMBERS WITH MTBI

¡ Ms. Davis has no relevant financial or non-financial relationships to disclose.

¡ Ms. Miller has no relevant financial or non-financial relationships to disclose.

¡ Ms. Scaramelli has no relevant financial or non-financial relationships to disclose.

¡ LCDR Sents has no relevant financial or non-financial relationships to disclose.

DISCLOSURES

Describe how a diverse team of clinicians addresses the benefits and challenges of an interdisciplinary

treatment approach for Active Duty Service Members (SM) following mild traumatic brain injury (mTBI)/concussion. The general mission, staffing, goals, patient population, and discipline-specific

information of the Intrepid Spirit Concussion Recovery Center (ISCRC) will be shared.

ABSTRACT

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Identify the benefits and challenges of an interdisciplinary approach in treatment of mTBI in the military population. Describe how to treat multiple mTBI symptoms through interdisciplinary collaboration. Recognize the differences in treatment of the military population following mTBI.

LEARNER OUTCOMES

The NICoE approach to the evaluation and treatment of SMs with the challenging co-morbidity of TBI and psychological health (PH) concerns can be described as patient-centered, utilizing a holistic, integrative and interdisciplinary model.

Evaluation and care are done in a family focused, collaborative environment that promotes physical,

psychological and spiritual healing in order to reduce suffering, instill hope, and address moral injury.

The ISCRC is the focal point for all referrals to NICoE from

the greater Eastern NC region for the Navy and Marine Corps. The intent is for patients to be referred to NICoE

when all local resources have failed.

NATIONAL INTREPID CENTER OF EXCELLENCE (NICOE)

Naval Hospital Camp Lejeune (NHCL)

We serve our military community through

excellence in: Operational Readiness,

Patient and Family Centered Care, and Professional

Development

ISCRC

We treat the physical,

emotional, and spiritual injuries of SMs who suffer

from a mTBI through a holistic, family centered,

interdisciplinary, integrative health care paradigm.

MISSION STATEMENT

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¡  Return patients suf fering from the ef fects of mTBI to their highest possible level of function.

¡  Identify and develop comprehensive cl inical programs of treatment to include measurable outcome metrics to establish and validate “best practice” models.

¡  Enhance basic understanding and provide support for our service men & women and their famil ies as it relates to their medical condit ion by providing pathways for recovery via classroom, individual learning sessions, wellness activit ies and resi l iency programs.

¡  Identify and participate in research opportunit ies in conjunction with NHCL research directorate to contribute to the scientific TBI body of knowledge.

¡  Develop continuum of care between primary care and forward deployed acute TBI treatment programs.

ISCRC GOALS

A diagnosis of mTBI should be made when there is an injury to the head as a result of blunt trauma, acceleration or deceleration forces, or exposure to blast that result in one or more of the fol lowing condit ions: a. Any period of observed or self -reported:

§  Transient confusion, disorientation, or impaired consciousness (AOC) §  Dysfunction of memory immediately before or after the time of injury (PTA) §  Loss of consciousness (LOC) lasting less than 30 minutes

b. Observed signs of neurological or neuropsychological dysfunction:

§  Headache, dizziness, irritability, fatigue or poor concentration, when identified soon after injury, can be used to support the diagnosis of mTBI, but cannot be used to make the diagnosis in the absence of LOC or AOC.

VA/DOD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF CONCUSSION/MTBI (2009)

The severity of TBI must be defined by the acute injury characteristics and not by the severity of symptoms at random points after trauma.

Individuals who are on active duty and present with symptoms related to documented or reported history of concussion are candidates for

evaluation and treatment at the ISCRC.

VA/DOD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF CONCUSSION/MTBI (2009)

Criteria Mild Structural imaging Normal AOC* A moment

PTA 0–1 day LOC <30 min

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Facilitates frequent communication between patients and the treatment team

Shares information about the effects of various

treatment modalities between staff members and patients, refining and modifying those treatments

accordingly

Reinforces the positive effects of these interventions, achieving a synergy of effect to

promote the recovery process

INTERDISCIPLINARY TREATMENT

16 Week Program

Neurology Speech Therapy

Pastoral Care

Educational Outreach

Occupational Therapy

Case Management

Mental Health

Physical Therapy

Neuropsychology

Medical

Admin

16 Week Program

DAY

1

DAYS

2-‐10

INITIAL

EVALUA

TIONS

DAYS

10-‐14

ITT INITIAL

ITT INTERIM I

DISCHARGE P

LANN

ING

WEEK 6

WEEK 10

ITT INTERIM II

DISCHARGE PLANN

ING

WEEK 14

ITT INTERIM III

DISCHARGE PLANN

ING

TYS A

PPT W

ITH

PA & RN

DISCHA

RGE A

PPT

WEEK 16

INTAKE APPT

FINAL APPT W

ITH

PA & RN

TYS – Tell Your Story ITT – Interdisciplinary Treatment Team

TIMELINE

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Core Services ¡  Intake & Orientation ¡ Tell Your Story ¡  Initial core evaluations

§ Medical (PA) § Speech Pathology § Occupational Therapy § Physical Therapy § Mental Health § Case Management

Additional services ¡ Neuropsychology ¡ Neurology ¡ Sports Medicine ¡ Pastoral Care ¡ Complementary and

Alternative Medicine ¡ Defense and Veteran’s

Brain Injury Center Educational Outreach

COMPONENTS OF INTERDISCIPLINARY TREATMENT

¡ SM’s initial appointments ¡ Completion of intake packet

§ Initial symptom questionnaires § Neurobehavioral Symptom Questionnaire (NSI)

¡ Order labs ¡ Schedule initial core evaluations ¡ Orientation provides overview of concussion

symptoms and ISCRC program, including traditional and complementary therapies and expectations for recovery

INTAKE AND ORIENTATION

Interdisciplinary treatment is focused on reducing SM’s physical and psychological pain by thoroughly

evaluating each individual case, identifying any underlying or comorbid issues, and ensuring an

accurate diagnosis and customized treatment plan.

An opportunity for the patient to provide a thorough case history ONE time.

Begin to develop interdisciplinary patient goals

TELL YOUR STORY

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¡ Treatment team leaders ¡ Perform medical evaluations ¡ Order and interpret lab and diagnostic studies ¡ Make appropriate subspecialty referrals ¡ Prescribe medications ¡ Perform periodic re-evaluations ¡ Prepare SMs for successful return to full duty or

transition to civilian life, as appropriate

MEDICAL (PA)

Components of Cognitive-Communication Evaluation

Attention Memory

Executive Functions Pragmatics

Assistive Technology Language and Literacy

Oral-Facial Voice

Fluency

SLP

¡  Interview and case history § Educational history § Caregivers § Medical Record Review § Patient report of symptoms

¡ Subjective questionnaire § LaTrobe Communication Questionnaire (LCQ) § Mayo-Portland Adaptability Inventory (MPAI) § Military Independent Activities of Daily Living (MIADL) § Behavior Rating Inventory of Executive Function (BRIEF-A)

SLP EVALUATION

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¡ Formal Assessment § Repeatable Battery of the Assessment of

Neuropsychological Status (RBANS) § Functional Assessment of Verbal Reasoning and Executive

Strategies (FAVRES) § Rivermead Behavioral Memory Test (RBMT) § Scales of Cognitive Ability for Traumatic Brain Injury

(SCATBI) § Attention Processing Training Test (APT) § Cognitive Linguistic Quick Test (CLQT)

SLP EVALUATION

Education

Concussion symptoms

Overlap with

psychological health

Cognitive

performance

SLP TREATMENT

High alert Startled easily

Fearfulness Flashbacks Nightmares

Guilty feelings Avoidance Numbness

Self-destructive

behavior

Insomnia/Fatigue

Impaired memory

Poor concentration

Depression

Anxiety

Irritability

Dizziness/Balance

Headache

Nausea

Sensitivity to light and sound

Vision changes

Impulsivity

PTS Concussion

https://dvbic.dcoe.mil/material/concussionmild-traumatic-brain-injury-and-posttraumatic-stress-disorder-fact-sheet

¡ Education and awareness ¡ Remembering appointments, tasks, medications,

belongings ¡ Modifications, strategies for attention ¡ Organizational strategies for medical information, home-

related tasks, work-related tasks ¡ Time management, schedules, planning ¡ Word finding strategies ¡ Strategies to aid in success in academic environment ¡ Referrals as needed to audiology and neuropsychology ¡ Needs assessment and training for assistive technology §  Computer/Electronic Accommodations Program §  Semper Fi Fund

SLP TREATMENT

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¡  The SLP’s role in Assistive Technology §  Helping the team to consider co-morbid and other

factors in the selection process §  Educating the team about technological features

and benefits §  Rationale for AT patient goals

¡  Apps most recommended to Service Members

INCORPORATING ASSISTIVE TECHNOLOGY (AT) INTO INTERDISCIPLINARY TREATMENT

ASSISTIVE TECHNOLOGY: THE SLP’S ROLE

¡  Identify Assistive Technology (cognitive aids) needs during the initial evaluation, and/or throughout the duration of the treatment plan.

¡ Assist with the provision, use, or modification of cognitive aids, to include supportive hardware.

¡  Incorporate the use of cognitive aids as external strategies during therapy sessions to enhance and support communication, memory, attention, organization, reading, and writing skills.

¡ Work collaboratively with interdisciplinary team members to help restore the SM’s independence and return to full duty or the community.

HELPING THE TEAM TO CONSIDER CO-MORBID FACTORS AND THEIR IMPACT ON

THE SELECTION OF COGNITIVE AIDS ¡ Pain (Headaches) – lighting may be a factor; mobile

devices may require adjustment in lighting, or paper/pencil organizers may be the best solution

¡ Anxiety – may choose fewer apps overall or start with those that promote deep breathing and relaxation before introducing new apps

¡ Dizziness – zooming or animated icons ¡ Sleep – too many steps, lengthy tasks, may adjust times

in which SM uses apps to peak arousal times ¡ Tinnitus – may require background white noise; hearing

aids when loss has occurred, continued use of earplugs when exposed to extreme noises

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EDUCATING THE TEAM ABOUT TECHNOLOGICAL FEATURES AND BENEFITS

¡ Discuss types of operating systems (iOS vs Android) to avoid patient confusion.

¡ Ensure accessibility settings are correct ¡ Are team members considering price points, upgrades,

longevity, reviews, etc.? ¡ Emphasize apps/features that address more than one

symptom to eliminate or reduce the chances of overwhelming the SM (i.e., PTSD Coach/Concussion Coach).

¡ Using technology to improve patient care in each discipline (tracking medications, symptoms)

ADDITIONAL CONSIDERATIONS FOR SERVICE MEMBERS

¡ Physical limitations ¡ Family support (spouse living at home or away) ¡ Mental health (PTSD, depression) ¡ Home environment (barracks, off-base housing) ¡ Transitional support ¡ Knowledge base of technologies ¡ Life goals

RATIONALE FOR AT PATIENT GOALS

¡  Patient may be using technology already available ¡  Socially acceptable ¡  Technology can be used across multiple settings and

situations ¡ More familiar to family members/caregivers (smartphone,

etc.) ¡ More motivating to use Ex. I want to use my technology to help me remember to do weekend errands when my wife asks me. Ex. I want to use technology to help me understand what I am reading when I am taking my online college course.

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INTERDISCIPLINARY TEAM APP RECOMMENDATIONS

Neurologists/PAs

¡ Sleep ¡ Headache Tracking ¡ White Noise ¡ Pillboxie ¡ mTBI pocket guide Primarily based on VA/DoD list of approved apps.

Neuropsychologists/Social Worker/Pastoral Care/OT ¡ PTSD Coach ¡ Concussion Coach ¡ CBT-I ¡ Breathe2Relax ¡ Virtual Hope Box


Speech Pathologists Attention/Concentration ¡ Stay on Task (Android) ¡ Mind Games (both)

Time Management/ Organization ¡ Wunderlist (iOS, new) ¡ To doist (both)

Executive Functioning ¡  Manage My Fatigue (iOS) ¡  Elevate (both) ¡  Lumosity (both) ¡  Peak (both)

Speech Pathologists Reading ¡  iBooks (iOS)

Writing ¡ Wunderlist (iOS, new) ¡ To doist (both) ¡ Dragon Dictation (iOS) ¡ AudioNote

Memory ¡  Reminder (both) ¡  Calendar (both) School/Vocational Pursuits ¡ Evernote (iOS);

Everstudent (Android-student planner)

¡ One Note (both) ¡ Simplenote (both)


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¡ Cognitive-Communication group ¡ Communication Skills group ¡ Creative Writing group ¡ Photography group ¡ Return to Community group ¡ Return to Duty group

SLP GROUPS

COGNITIVE-COMMUNICATION GROUP Focuses on improving memory, attention, and word finding/

retrieval by reinforcing strategies earned throughout individual treatment sessions.

1x/Week Open group for 8 SMs after team discussion

SLP GROUP TREATMENT

COMMUNICATION SKILLS GROUP

This group helps SMs to use emotions, words, and body language to express themselves and respond to

information, ideas, and feelings in a way that helps to build and/or improve relationships at home, work, and in the

community settings.

1x/week for 6 weeks Closed group of 6 SMs after team discussion

SLP GROUP TREATMENT

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CREATIVE WRITING GROUP

SMs are given the opportunity to tell their story, to create a new story, and to share those stories as a means of facilitating

healing. Candidates for this group do not have to be proficient in writing. From a behavioral health perspective, it is a means of telling their story in a safe environment while at the same time

improving memory and cognition.

1x/week for 5-6 weeks Open group for 6 SMs after team discussion

Collaborate with LCSW

SLP GROUP TREATMENT

PHOTOGRAPHY GROUP

Designed to stimulate interest in enjoyable activities and a means of improving coping and self- awareness, while reducing anxiety and

stress and improving memory and cognition. It stimulates creativity, organization, decision making, and memory through didactic

teaching, teach-back; and verbal report of experiential decision making. Candidates for this group do not have to have any experience with photography nor do they need to own a camera as cameras are

provided for group use.

1x/week for 8 weeks Closed group for 6 SMs after team discussion

Collaborate with LCSW and Active Duty Combat Photographer

SLP GROUP TREATMENT

RETURN TO COMMUNITY GROUP

Focuses on community re-entry skills within an interdisciplinary team to maintain and generalize learned skills from the clinical

setting.

2x/week for 4 weeks Closed group for 6 SMs after team discussion

Collaborate with OT, PT, MH Outside resources utilized, including Dietician, Academic

Advisor, VA representatives, Recovery Support Specialist, etc. Ends with outing planned by SMs

SLP GROUP TREATMENT

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RETURN TO DUTY GROUP

The group will focus on functional application of the basic skills learned from the program for improved job resilience. The

overall goal of the Return to Duty Group is to assess how well an individual is able to apply the skills they learned in individual

treatment sessions during more functional based tasks.

1x/week for 4-5 weeks Closed group of 6 SMs after team discussion

Collaborate with OT, PT, MH, Active Duty liaisons from Wounded Warrior Battalion

Ends with functional simulation

SLP GROUP TREATMENT

Vision Therapy

Saccades/Pursuits

Accommodation

Convergence

Biofeedback and AVE

Anxiety/ PTSD

Pain/Self-Regulation

Insomnia

Patient Education

Building Habits/Routines

DVBIC Handouts

Improving Self-Awareness

OCCUPATIONAL THERAPY

Executive Functioning

Skills

Attention/ Completion of

Task

Organization and Planning

Problem Solving/Coping

Skills

Visual Perceptual

Skills

Visual Memory

Visual Reaction Time

Depth Perception

Physical Training

Promotes Cell Growth

Endurance

Mental Clarity

OCCUPATIONAL THERAPY

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¡  Impairment based treatment § Oculomotor/balance eval

¡  Goal of evaluation is to identify specifically what is causing the patient’s difficulties §  Is the SM most limited in

their ability to balance by issues related to an inner ear weakness?

§ Or are they most limited by pain? Sometimes pain has be addressed first to allow balance to improve.

VESTIBULAR PHYSICAL THERAPY

MENTAL HEALTH

When symptoms SIGNIFICANTLY

DISRUPT a person’s life we say the person has a mental disorder or a

mental illness.

The mental health disorders typically seen at ISCRC include: ¡ Military Combat Stress

Reaction ¡ Adjustment Disorder with

Mixed Emotions ¡ Depression ¡ Anxiety ¡ Post Traumatic Stress

Disorder

A doctoral level professional within the field of psychology with special expertise in the applied

science of brain-behavior relationships. Neuropsychological evaluations are used to measure

changes in cognitive functioning that may result from concussion. These evaluations also help clarify

the impact of other factors on cognition, such as sleep disturbance, mood and emotional changes,

and pain.

NEUROPSYCHOLOGY

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NEUROLOGY ¡  Headache Management when

needed ¡  Assist in management of

neurologic symptoms when needed §  Seizures §  Tremor conditions §  Numbness §  Weakness

¡  Evaluate neurologic abnormalit ies that medical (PA) finds

¡  Write Medical Evaluation Board addendums

SPORTS MEDICINE ¡  Team coordination ¡  Patient education ¡  Osteopathic Manipulative

Treatment (OMT) for the management of headache and acute musculoskeletal condit ions

¡  Joint injections ¡  Trigger point injections ¡  Migraine protocol botox

injections ¡  Sphenopalatine ganglion block

procedure for headache ¡  Coordinates a team of OT and PT

in order to achieve the ult imate goal of balance, function, and musculoskeletal injury recovery

ADDITIONAL MEDICAL

Case Management

Assist with obtaining needed referrals and coordinating

care

Assist with accessing community and/or military

resources, as well as treatment options

Review provider(s) plan of

care and review with SM and family, as well as compliance

with treatment regimen

Pastoral Care

Promote the religious, spiritual, and

moral well being of our patients and their families.

Provides individual and

couples counseling

Leads various groups

Other

§  Participants: SM, PA, SLP, OT, PT, MH, Neurology, Case Management, Wellness Coordinators

§  Engages SM in their individual plan of care as an active participant

§  Promotes greater team communication §  Early detection of compliance difficulties §  Allows for earlier communication with SM’s

command, if needed

INTERDISCIPLINARY TREATMENT TEAM MEETINGS

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¡  CBT for Anxiety and Irritability: Psychologist and LCSW

¡  CBT for Insomnia: LCSW and RN ¡  CBT for Pain Management:

Psychologist, LCSW, and PT ¡  Creative Writing: LCSW and SLP ¡  Art Therapy: LCSW and Art

Therapist ¡  Photography: LCSW and SLP ¡  Mindfulness Based Stress

Reduction, iRest, Mindful Meditation and Yoga: Pastoral Counselor

COMPLIMENTARY AND ALTERNATIVE MEDICINE (WELLNESS)

Courtesy of ISCRC Art and Writing Groups

Benefits Challenges

Interdisciplinary Treatment Team meetings Limited communication with out-of-network referrals

Daily informal collaboration Logistics of interdisciplinary scheduling

Bi-monthly staff education and training Redundancy of services

Numerous program options for wounded warriors

Overwhelming program options for wounded warriors

Communication with military sources, i.e. vet center, base education center, vocational rehab, Medical Officer, Wounded Warrior

Battalion, etc.

Co-morbidities: PTSD, combat stress, anxiety, depression, anger/irritability,

substance abuse

Access to research, active participation in research/program development, outcome measures to support research protocols

Inconsistent attendance/progress: high operational tempo, deployments, trainings,

temporary/permanent change in duty station (TAD/PCS), command, duty status,

legal issues, MEB

The DVBIC Program serves to identify, track and follow-up with SMs and veterans who were

injured while serving in support of OIF/OEF/OND and are symptomatic subsequent to a

diagnosis of TBI. Families and caregivers of these warriors are also provided support

through the program.

DEFENSE AND VETERANS BRAIN INJURY CENTER (DVBIC)

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¡  Traumatic Brain Injury: A Guide for Caregivers of Service Members and Veterans

¡  A Parent’s Guide to Returning Your Child to School After a Concussion

¡  Back to School Guide to Academic Success After Traumatic Brain Injury

¡ DVBIC Return to Activity Guidelines https://dvbic .dcoe.mi l/s i tes/default/f i les/2013_PRA_Rehab_PES_FINAL.pdf

Free materials either shipped or downloadable for TBI http://dvbic.dcoe.mil/

DVBIC RESOURCES

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RESEARCH

¡ Validating Cognitive Markers of Hippocampal Deficits in Marines with PTSD

¡ Novel Approaches to the Analysis of Clinic & MRI Data in Marines with a History of Possible mTBI

¡ Discovery and Validation of Peripheral Biomarkers of TBI

¡ NHCL Clinical Research Database to Study Traumatic Brain Injury and Psychological Health Outcomes in Military Personnel

¡  25 year old infantryman ¡  mTBI injury: Inside an MRAP when an IED was detonated approx. 15 feet from the rear of the vehicle. States that he lost consciousness for less than one minute. Est imated that i t was 80-100 lbs of explosives. Several other Marines were wounded from the blast . Af terwards, he repor ts r inging in ears, disorientat ion, headache, and s luggishness. He was evaluated by MO and Corpsman 14 hours af ter blast occurred. States that he fai led the MACE exam several t imes. Was kept behind the wire for several weeks. ¡  Mild depression and anxiety ¡  Wife and chi ldren l ive in another state ¡  Complains of insomnia (3 hours/night) , increased irr i tabi l i ty, l ight sensit iv i ty

and blurry v is ion, migraines 3 to 4 days/week, decreased concentrat ion, memory dif f icult ies, “s lurred speech”

¡  Uses smartphone for text ing, talking, and gaming ¡  Planning to remain on act ive duty ¡  Wants to eventual ly return to col lege when he gets out

CASE STUDY

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Referral

Intake: RN assigns team

Phase 1: Clinical

Evaluations

Medical

Rehab

Phase 2: Treatment

Medical

Rehab

CAM Therapy

Phase 3: Reintegration

Return To Duty

Interdisciplinary Treatment Group

Goal: job resilience

Objective: SMs generalize strategies

Scheduling: 4-5 weeks with

PT, OT, MH

Functional simulation

Return to Community

Interdisciplinary Treatment

Group

Goal: Community

re-entry

Objective: SMs generalize strategies

Scheduling: 4 weeks with PT,

OT, MH

Outing planned by SMs

Medical Eval Board, End of Active Service,

Follow up referrals

Tell Your Story & Orientation

¡  Patient care is priority ¡  Professional collaboration ¡  Co-treating if possible ¡  Respect for other professionals ¡  Patience ¡  Interdisciplinary team meetings ¡  Follow through with recommended referrals ¡  Communication!

HOW DOES THIS APPLY TO YOU?

¡ Doris Davis § Email: [email protected]

¡ Genie Miller § Email: [email protected]

¡ Ashley Scaramelli § Email: [email protected]

¡ LCDR Sents § Email: [email protected]

CONTACT INFORMATION

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¡  Bogdanova, Y., & Verfaellie, M. (2012). Cognitive sequelae of blast-induced traumatic brain injury: Recovery and rehabilitation. Neuropsychol Rev, 22 , 4-20.

¡  Braverman, S., Spector, J. , Warden, D., Wilson, B., Ell is, T., Bamdad, M., & Salazar, A . (1999). A multidisciplinary TBI inpatient rehabilitation programme for active duty service members as part of a randomized clinical trial. Brain Injury, 13(6), 405-415.

¡  Cornis-Pop, Mashima, & Roth. (2010). Evaluating cognitive-communication in persons with mild TBI. Retrieved from http://www.asha.org/Events/convention/handouts/2010/SC27-Roth-Carole

¡  Defense and Veterans Brain Injury Center. (2015, March 30). Retrieved from https://dvbic.dcoe.mil/

¡  De Riesthal, M. (n.d.). Treatment of Cognitive-Communication Disorders Following Blast Injury. Perspectives of Neurophysiology and Neurogenic Speech and Language Disorders,58-64.

REFERENCES

¡  Dowds, M., Lee, P. , Sheer, J . , O'Neil -Pirozzi , T. , Xenopoulos-Oddsson, A . , Goldstein, R. , . . . Glenn, M. (2011). Electronic reminding technology fol lowing traumatic brain injury: Ef fects on t imely task completion. Journal of Head Trauma Rehabil i tation, 26 (5), 339-347.

¡  Helmick, K. , & Members of Consensus Conference. (2010). Cognit ive rehabil itation for mil itary personnel with mild traumatic brain injury and chronic post-concussional disorder: Results of Apri l 2009 consensus conference. NeuroRehabil i tation, 26 , 239-255.

¡  Joint Committee on Interprofessional Relations between the American Speech-Language-Hearing Association (ASHA) and Division 40 (Cl inical Neuropsychology) of the American Psychological Association (APA). (2007). Structure and function of an interdiscipl inary team for persons with acquired brain injury [guidelines]. Available at www.asha.org/policy.

¡  K.D. Cicerone, C. Dahlberg, K. Kalmar et al . , Evidence-Based Cognit ive Rehabil itation: Recommendations for cl inical practice, Archives of Physical Medicine and Rehabil i tation 81 (2000), 1596-1615.

REFERENCES

¡  Krug, H., & Turkstra, L. (2015). Assessment of cognitive-communication disorders in adults with mild traumatic brain injury. Perspectives of Neurophysiology and Neurogenic Speech and Language Disorders, 25 , 17-35.

¡  MacDonald, S. (Director) (2013, November 16). When "Mild" is not Mild: Managing Subtle but Significant Cognitive-Communication Deficits After ABI. 2013 AHSA Convention . Lecture conducted from American Speech-Language-Hearing Association, Chicago.

¡  Mashima, P. (2013). Rehabil itating post-deployment cognitive symptoms: Empowering change [PowerPoint sl ides]. TBI Grand Rounds, San Antonio Military Medical Center.

¡  Parrish, C., Roth, C., Roberts, B., & Davie, G. (n.d.) . Assessment of cognitive-communication disorders of mild traumatic brain injury sustained in combat. Perspectives of Neurophysiology and Neurogenic Speech and Language Disorders, 47-57.

¡  Schneider, S., Haack, L., Owens, J. , Herrington, D., & Zelek, A. (n.d.). An Interdisciplinary treatment approach for soldiers with TBI/PTSD: Issues and 0utcomes. Perspectives of Neurophysiology and Neurogenic Speech and Language Disorders, 36-46.

REFERENCES

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¡  Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York: The Guilford Press.

¡  The Management of Concussion/mTBI Working Group. (2009). VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI. VA/DoD Evidence Based Practice, 1-109. Retrieved from http://www.healthquality.va.gov/guidelines/Rehab/mtbi/concussion_mtbi_full_1_0.pdf

¡  The NICoE Patient Welcome Guide. (2015, January 1). Retrieved from http://www.nicoe.capmed.mil/Shared Documents/NICoE Patient Handbook_FINAL3.pdf

¡  Traumatic Brain Injury (Adults): ASHA's Evidence Maps National Center for Evidence-Based Practice in Communication Disorders. (2011). Retrieved from http://ncepmaps.org/atbi/

¡  Wild, M.R. (2012). Organize Your Life Using iOS 5 on the iPad, iPhone, and iPod Touch Making Cognitive Connections at Home, School, and Work . Laguna Hills, CA: ID 4 the Web.

REFERENCES