Acquired Brain Injury: Functional Evaluation Across Settings

Editor's Note: This text is a transcript of the course Acquired Brain Injury: Functional Evaluation Across Settings presented by Erin Mattingly, MA, CCC-SLP, CBIS

Learning Outcomes

After this course, participants will be able to:

• Explain the process of informal, observational assessment of patients who have sustained a head trauma.
• Identify the challenges associated with using formal assessment for traumatic brain injury evaluation.
• Identify suspected symptoms following traumatic brain injury evaluation.

Mechanisms and Symptoms of ABI

Let's start by reviewing acquired brain injury (ABI) and its mechanisms and symptoms. According to the Brain Injury Association of America, an ABI is an injury to the brain that is not hereditary, congenital, degenerative, or caused by birth trauma. Essentially, ABI occurs after birth and results in changes to the brain's neuronal activity, affecting the physical integrity, metabolic activity, or functional ability of the brain's nerve cells.

Traumatic brain injury (TBI) is a type of ABI that involves an alteration in brain function or other evidence of brain pathology due to an external force. TBIs can be classified as either closed (non-penetrating) or open (penetrating). An example of a penetrating injury would be a gunshot wound to the head, while a closed injury might be a traumatic brain injury resulting from a fall, where the skull remains intact without any penetration into the brain.

Non-traumatic brain injuries are those caused by internal factors. For example, a stroke, which can be due to hemorrhage or infarct, is a common type of non-traumatic brain injury. Other causes of ABI include anoxia (complete lack of oxygen to the brain), hypoxia (reduced oxygen levels), tumors, or the after-effects of tumor removal surgery. Additional neurological impairments like seizures or drug overdoses can also lead to acquired brain injuries.

ABI Severity

When assessing traumatic brain injury (TBI), there are different methods to evaluate severity, generally categorized into mild, moderate, and severe. However, recent discussions suggest that these classifications might require reconsideration. I read something just yesterday about the ongoing debate around how severity has been assessed over the years. It appears that what we once considered mild TBI can sometimes lead to complex, severe symptoms.

While this is an emerging topic and a bit beyond my current understanding, I noticed it in a press release or a LinkedIn post. I'm interested to see what experts in the field will determine regarding potential shifts in how we categorize the severity of traumatic brain injuries. But I digress; let's return to the current classifications, which are mild, moderate, and severe.

Rancho Los Omigos Scale

In traumatic brain injury (TBI), one common tool used to assess recovery is the Rancho Los Amigos Scale, originally designed to classify behavioral symptoms based on TBI severity and recovery progression. The scale began with eight levels, starting with Level 1, which indicates no response and total assistance, up to Level 8, indicating purposeful, appropriate behavior with minimal assistance. The scale has since been extended to ten levels, with Level 10 representing purposeful, appropriate, and modified independence.

I often joke that on any given day, I feel more like a Rancho Level 8 than a Level 10. We've all experienced days where our functionality isn't at its peak, but it's important to remember that the Rancho Scale is not linear or sequential. Individuals can move between levels, and recovery doesn't always follow a strict upward trajectory.

For example, a Level 3 response involves localized reactions to pain, such as moving away when someone pinches the scapula or applies a sternal rub. However, this level still requires total assistance. Individuals might skip Level 4 entirely—the agitated and behaviorally challenging stage—and move directly to Level 5, characterized by confused and inappropriate behavior without agitation, still requiring maximum assistance. This shows that recovery on the Rancho Scale can be unpredictable, with patients sometimes skipping levels or regressing.

Glasgow Coma Scale

Another common method for assessing the severity of TBI is the Glasgow Coma Scale (GCS). Similar to the Rancho Los Amigos Scale, the GCS was developed to define TBI severity, but it uses a different approach. The Glasgow Coma Scale evaluates a patient's responsiveness across three key areas: eye opening, verbal response, and motor response. Each of these categories is scored to determine the overall GCS score, indicating the level of consciousness and severity of the brain injury.

It's important to note that both the Rancho Los Amigos and Glasgow Coma scales are specifically designed for patients who have sustained traumatic brain injuries. They are not valid or reliable for assessing other types of brain injuries, such as those resulting from non-traumatic causes like strokes or tumors.

NIH Stroke Scale

To further define and standardize the assessment of stroke severity, the National Institutes of Health (NIH) developed the NIH Stroke Scale. This scale is designed to assess patients with strokes, which are a type of ABI but not TBI. The NIH Stroke Scale evaluates multiple aspects of a patient's neurological function, including level of consciousness, receptive and expressive language, motor weakness, visual symptoms, and sensory loss. This comprehensive evaluation helps healthcare providers understand the severity of a stroke and guides treatment planning.

It's important to highlight the difference between assessing severity in TBI and stroke. The Rancho Los Amigos and Glasgow Coma scales are specifically for traumatic brain injuries, while the NIH Stroke Scale is intended for stroke assessment. Occasionally, you might encounter medical residents or newer healthcare professionals who mistakenly apply the Rancho Los Amigos Scale to stroke patients. This confusion underscores the need for education and awareness among healthcare providers regarding the correct scales to use for different types of brain injuries. As an SLP,  be mindful of these distinctions and ensure that appropriate assessment tools are used based on the type of brain injury.

"Typical" Symptoms of ABI

The typical symptoms of ABI can apply to both strokes and TBIs. Although the presentation can vary, these symptoms generally include difficulties with attention, memory, and executive functioning, which involves the ability to plan, solve problems, recognize issues, implement solutions, and evaluate success.

Language-related problems are also common in ABI cases, which can manifest as aphasia, word-finding difficulties, or challenges with pragmatics and social skills. Swallowing issues, known as dysphagia, are another possible symptom.

Physical symptoms might include hemiparesis, which is paralysis on one side of the body, visual disturbances, ocular motor issues, and mobility problems.

These are typical symptoms of ABI, but every case is unique. The saying "If you've seen one brain injury, you've seen one brain injury" is quite accurate; no two cases are identical, and you can find different combinations and severities of symptoms across individuals. It is essential to recognize this uniqueness when addressing ABI symptoms.

Overview of Symptoms (Mashima et al., 2021)

Dr. Mishima's article provides a comprehensive overview of the symptoms associated with ABI, and it's a valuable resource if you're interested in recent research on the subject. Below is an overview of some of the common symptoms, particularly for mild brain injuries.

Among physical symptoms, headache is prevalent, along with light sensitivity, visual disturbances, sleep disturbances, and pain. Additional symptoms may include fatigue, tinnitus (ringing in the ears), dizziness, or other vestibular issues.

Emotional symptoms are also common, with patients often experiencing anxiety, increased irritability, and a tendency to become easily angry or frustrated. Other emotional signs may include impulsivity, low energy or motivation (which can be tied to emotional factors but may also reflect executive dysfunction), and depression.

Cognitive symptoms typically involve poor concentration, easy distractibility, memory deficits, slowed processing speed, problems with organization, difficulty multitasking, and difficulty making decisions.

Impact of Medication

When evaluating patients with ABI, we need to consider the impact of medications. This consideration extends across all severities and settings, from acute care ICU and acute rehab to community reentry. Medications can significantly affect your evaluation, daily function, and overall outcomes. Here are some key considerations:

• Pain Medications: Sedative pain meds like morphine, Vicodin, Percocet, and even neurontin can significantly impact alertness and activity levels. This sedation can affect how patients respond during evaluations and influence their day-to-day activities.

• Neurostimulants: Medications such as Ritalin, amantadine, Aricept, parlodel, and bromocriptine are intended to improve cognitive function and alertness. These medications can positively affect symptoms and improve responsiveness, but they may also have side effects that influence your assessment.

• Blood Pressure Medications: High doses of blood pressure medication can cause lightheadedness or headaches due to low blood pressure, while low doses may lead to other complications. It's essential to monitor how these medications are impacting your patient.

• Antiepileptics: Medications like kepra and dilantin, used to manage seizures, can have sedative effects. This sedation can contribute to fatigue, weakness, and pain, impacting the evaluation and treatment process.

Everyone reacts differently to medications, so it's important to consider this variability when assessing and treating patients with ABI. Some individuals are more sensitive to these drugs than others, and the side effects can vary widely. As you move through the evaluation and treatment phases, keep in mind that medications can influence a patient's responses, symptoms, and overall progress.

Post-Traumatic Amnesia

Post-traumatic amnesia (PTA) is a common condition that arises after a TBI. It typically presents in two ways.  Retrograde amnesia is the partial or total loss of the ability to recall events that occurred immediately before the brain injury. This type of amnesia usually decreases progressively as a person recovers. Initially, the patient might be unable to remember six months of events prior to the injury, but as they improve, this duration could shrink to three months, one month, or even less. 

Anterograde amnesia is a deficit in forming new memories after the brain injury, leading to decreased attention and inaccurate perception. This type of amnesia is often the last function to return following the recovery from loss of consciousness.

Understanding whether a patient is experiencing PTA is important for planning treatment and rehabilitation. The duration of PTA varies from a few minutes to days or even months, depending on the severity of the TBI. Recognizing the type and duration of amnesia helps medical professionals tailor their approach and manage expectations for recovery.

The severity and duration of PTA are directly related to long-term outcomes after a TBI. The longer a person experiences PTA, the more likely it is that the severity of their injury will impact their recovery and return to normal function. Understanding when a patient is in PTA is critical for medical professionals, especially SLPs because it affects treatment plans.

When someone is in PTA, their declarative memory is impaired, meaning they have difficulty forming new memories. This has significant implications for therapy and rehabilitation, as assessing and teaching new skills or strategies can be challenging if the patient cannot remember them. However, implicit and procedural memory typically remains intact during PTA. This means that while the patient may not recall new information, such as a name or specific details, they can still remember how to perform basic tasks like tying shoes, brushing teeth, or other familiar routines, depending on the extent of other impairments.

When dealing with PTA in the context of treatment and assessment, it's important to understand the limitations it poses. PTA can significantly affect a patient's orientation, which is the ability to recognize their identity, location, time, and general context. This orientation is a key indicator of whether someone is still experiencing PTA.

If a patient is in PTA, their ability to learn or retain new information is severely compromised. This makes it challenging to teach them compensatory strategies, which are often used to help patients manage their daily activities or overcome specific deficits. Attempting to implement these strategies with someone in PTA is likely to be ineffective because they won't retain the necessary information or steps.

One common practice in rehabilitation settings is the use of orientation groups, where patients gather to discuss basic information like the date, location, and current events. These groups can be beneficial for social interaction and creating a sense of community among patients. However, if a patient is still in PTA, attending such groups may not be of much value because they are unlikely to retain any of the information discussed during the sessions.

Agitation vs. Motor Restlessness

In the acute phase of treatment and rehabilitation, agitation usually happens within the first week after a traumatic brain injury, depending on the injury's severity and the level of consciousness. When patients are agitated due to the injury, they're generally in the PTA stage, characterized by motor or verbal outbursts that disrupt patient care or necessitate physical or chemical restraints to prevent harm to people or property.

Rancho Level 4 is notorious for its sometimes dangerous agitation. This level can lead to impulsive, erratic, and potentially harmful behaviors. Research suggests that between 33-50% of patients with TBI experience agitation, with higher frequencies observed in those with severe injuries. However, motor restlessness is often mistaken for agitation, but the two are distinct.

Motor restlessness involves behaviors that interfere with staff work and may require some action, like changing activities, but it does not reach the severity of agitation and isn't continuous. For example, a patient might continuously kick their foot while you're working with them. As they get more distracted, the kicking could intensify, which can be disruptive. But if you change their environment, like moving them to a quieter area or shifting their position, the restlessness can subside, indicating it's not true agitation.

Restlessness can be part of agitation, but agitation is not part of restlessness. It is also critical to differentiate agitation from other cognitive symptoms or behaviors, which can be challenging.

An agitated patient in the PTA phase struggles with attention and memory, making it difficult for them to focus on or remember treatment. In contrast, a restless patient, who may also exhibit heightened activity, can usually be redirected to participate in evaluation and treatment if provided with a structured yet flexible environment. For example, if a patient is too restless for a typical therapy gym setting, moving to a quieter, less stimulating area or conducting the evaluation in their room can help manage their restlessness.

The distinction between agitation and restlessness is critical for patient and healthcare provider safety. Agitated patients can be dangerous and may require additional precautions to ensure the safety of everyone involved. Proper safety measures, such as using physical or chemical restraints when necessary, can prevent harm to the patient, the therapist, and other patients.

Agitation often occurs in patients at Rancho Level 4, indicating they have moved out of Rancho Level 3, which is characterized by a minimally conscious state. As they progress into Level 4, these patients become more responsive and aware, but they may also display increased sensitivity to pain and other stimuli.

Patients at a Rancho Level 4 are often alert and in a heightened state of activity, leading to purposeful but impulsive behavior. This might include attempting to remove medical restraints or tubes or trying to get out of bed, posing safety risks to themselves and others. Differentiating between agitation and motor restlessness is crucial in these situations. Agitated patients are more likely to perform motor activities like sitting, reaching, or walking without any apparent purpose or direction. These activities often seem random or chaotic and aren't prompted by any specific request.

Despite their active behavior, these patients often lack the capacity to form new memories due to the ongoing effects of PTA. This can lead to them appearing engaged in physical activities like walking around, talking, or interacting with others but without meaningful recall of their actions or surroundings. 

When patients are in the post-traumatic amnesia stage, their movements are generally not purposeful, except for attempts to escape pain. They have no short-term memory and only brief moments of sustained, alternate, or divided attention. They might cry out or scream, reacting disproportionately to stimuli, even after those stimuli are removed. These patients may display aggressive or flight behavior. Their mood can shift dramatically from euphoric to hostile, and they often struggle to cooperate with treatment efforts.

Patients in this stage often produce verbalizations that are incoherent or inappropriate for the current activity or environment. This has safety implications, but it's also important to consider when working with a Rancho Level 4 patient who has incoherent verbalizations. You don't want to prematurely diagnose a language disorder, as these symptoms might resolve as they progress to a Rancho Level 5 or higher. As patients emerge from the post-traumatic amnesia stage, their language skills might improve, indicating that their incoherent verbalizations were tied to their injury's severity and not a permanent language disorder.

Patient Safety and Your Safety 

I mentioned briefly the importance of safety for both you and your patients. When dealing with someone in the Rancho Level 4 stage, always be aware of the nearest door and maintain access to it. Keep a safe but comfortable distance from the patient and stay mindful of their needs. Check whether they are hungry, agitated, lonely, or tired (the "HALT" factors). Cognitive fatigue can significantly impact them. Even as people without brain injuries, we can feel exhausted at the end of a workday. Now consider a person with a brain injury—if we push them through treatment sessions, and they're also dealing with the effects of a Rancho Level 4 state, they will be burning energy at a much faster rate.

Their constant motor restlessness, mood swings from euphoria to hostility, and attempts to remove restraints or other purposeful but non-productive activities all drain energy. This can lead to severe cognitive fatigue, which in turn may trigger more physical outbursts or agitation.

It's important to acknowledge and empathize with your patient. Even in a heightened state, use a calm tone and allow for safe, increased movement to help them distract themselves and expend energy. As mentioned earlier, they may be able to walk and move independently, assuming they don't have any physical deficits. Allowing them to move and "burn off" energy can be helpful in reducing overstimulation and agitation.

The use of wander guards on units can be helpful in allowing patients to walk freely while preventing them from exiting the area. These guards can be in the form of a bracelet or ankle monitor. For patients who are not safe to move independently, a posey bed is useful. This bed has a net or mesh sides, allowing the patient to thrash or move around without falling out or harming themselves. Additionally, keeping patients within a locked unit is another safety measure to consider for those at risk of wandering or needing additional supervision.

When is it appropriate to complete
a standardized formal assessment versus an informal assessment?

Right now, we're focused on acute care and acute rehab. It's interesting to discuss this because insurance companies often want to see standardized assessments to determine the length of treatment time and how long a patient can stay in a specific unit. However, if someone is in the acute stage, it might not be appropriate to complete a standardized assessment.

Why? Well, if a patient is in post-traumatic amnesia, they are not forming new memories, not oriented, and not able to maintain attention. Conducting a standardized assessment under these conditions is unlikely to yield reliable or useful results.

So, a standardized assessment of someone in the acute stage may not provide accurate information about their areas of deficit because they have not yet reached a stable state where a reliable assessment can be performed. During the acute stage, informal assessments and functional observations are typically more suitable. This approach allows you to gauge a patient's abilities in a more flexible and contextually relevant manner. However, you need to ensure that your patients receive the necessary insurance coverage for their treatment, and insurance may require formal assessments. If you need to conduct a formal assessment, there are approaches you can use, which we'll discuss later. But if possible, opting for an informal screening method can yield more accurate insights during this early phase, especially for patients in the Rancho 4 level or those emerging from it.

Things to Consider: Assessment

Before assessing your patient, consider several critical factors. We already discussed the impact of medications, but it's also essential to evaluate their level of consciousness. The Rancho Scale or the stroke scale can guide you in determining a patient's awareness level. Can they focus on you or someone else in the room? Can they concentrate on tasks like reading or cancellation activities? Understanding these aspects will help you gauge their readiness for assessment.

Examine their physical symptoms. Look for hemiparesis, left-side neglect, or other motor impairments. Also, check for wounds or other physical injuries that might affect their comfort or ability to participate in the assessment. 

Assess their communication. Start by considering their pre-injury communication style and primary language. Note any language disorders that might have developed after the injury. These insights will shape your approach to therapy and communication with the patient.

Family dynamics are crtical, especially in acute settings where caregivers are typically present. Observe these dynamics, as they often become more pronounced when a person is severely injured. Look for signs of codependency or overstepping, where family members might be too involved in caretaking, potentially hindering the patient's recovery. Instead, aim to empower families to support, not enable, the patient's independence. This awareness will guide you in utilizing family dynamics positively in your treatment sessions, allowing you to work with families effectively in the longer term.

Lastly, remember to consider agitation and motor restlessness, along with post-traumatic amnesia. These factors can significantly impact your assessment and treatment strategy, requiring careful observation and adaptation to ensure patient safety and effective therapy.

Informal Assessment and Interdisciplinary Intake

Functional assessment in any patient population, including this one, is extremely important as it gives a snapshot of how the patient is able to get by in the day-to-day with their injury or diagnosis. Think about your own experiences in school—you may have excelled in classroom activities but struggled with test-taking. This demonstrates the value of functional observation over standardized assessment, emphasizing the importance of informally observing functional tasks.

Consider simple tasks to gauge a patient's capabilities. Can they remember the steps to brushing their teeth? When you introduce yourself, do they engage with you? Functional tasks provide a clearer picture of how a patient manages daily activities. It’s about getting away from worksheets and workbooks and focusing on real-life scenarios within the patient's environment.

For instance, can the patient safely get out of a wheelchair independently despite being hemiparetic? These observations are critical as they offer insights into the patient's awareness, problem-solving abilities, and memory function, linking back to post-traumatic amnesia. Understanding these factors can guide treatment and ensure patient safety, providing a more accurate reflection of their day-to-day functioning.

Of course, if you're informally observing functional tasks, you can think of it therapeutically as well. Increasing the complexity of tasks can serve as both an evaluation and treatment. For example, during a scavenger hunt around the ABI unit, you can assess and treat simultaneously by observing how the patient responds to tasks with varying levels of complexity.

Start with a simple task like counting the number of exit signs as you walk with the patient or push them in a wheelchair. If they do well with that, you can add another layer of complexity. For instance, ask them to count the number of fire extinguishers as you continue through the unit. To increase complexity further, ask the patient to greet each nurse they pass by, assessing their social engagement and attention to their environment. 

If the tasks become too complex, you can decrease complexity by removing stimulation or simplifying the instructions. This approach allows you to gauge the patient's ability to process information, follow directions, and engage with others in a real-world setting. It's an adaptable method that can be adjusted on the fly, providing valuable insights for both assessment and treatment.

When I refer to screeners, I'm talking about informal tools developed by hospital systems to assess a patient's cognitive and functional abilities quickly. These screeners aren't standardized tests, but they might use elements from various formal assessments. They could include tasks like naming objects, orientation checks, or simple cancellation tasks. Screeners help establish an initial sense of a patient's deficits, even in early recovery stages, such as Rancho 3 or 4. They allow you to identify immediate needs without a full standardized assessment. 

With Rancho 3, the focus isn't on formal assessments like the Western Aphasia Battery or the R-BANS. Instead, you're trying to understand the patient's memory and cognitive abilities through less formal means, not relying on standardized tests. This approach helps structure treatment during the early stages when standardized assessments might not be suitable, especially if the patient isn't fully oriented. Starting with a screener can give you a clearer picture of the patient's current capabilities without overwhelming them with more complex assessments.

An interdisciplinary group intake is a collaborative approach where different therapy professionals—like occupational therapists, physical therapists, and speech pathologists—come together to assess a patient on the first day. Although not every hospital supports this approach, it's ideal for holistic patient care.

The team goes in together to conduct a comprehensive assessment. The physical therapist might focus on the patient's physical abilities, like transfer status, while the occupational therapist observes fine motor skills and everyday activities. As a speech pathologist, your role would be to evaluate cognitive function and communication skills.

During the group intake, everyone contributes to a broader understanding of the patient's condition. For example, when the physical therapist is transferring a patient out of bed, you can assess the patient's awareness and safety—do they know they can't move their left side? Are they able to follow instructions, or are they agitated? This collaborative approach ensures that all aspects of the patient's care are considered, leading to more effective treatment planning and coordination among the therapy team.

JFK Coma Recovery Scale (CRS)-Revised

Let's explore the JFK Coma Recovery Scale (CRS) in the context of patients with low-level brain injuries, typically falling within Rancho Levels 1-3. It's essential to acknowledge that these patients can and should be engaged beyond conventional coma-stim interventions, offering various ways to assess their actual function.

The CRS is a prime example of this approach. Initially described by researchers in 1991 and revised in 2004, it assists in differential diagnosis, prognostic evaluation, and treatment planning for patients with disorders of consciousness.

With the CRS, healthcare professionals can determine whether a patient is minimally conscious, in a vegetative state, or transitioning along the continuum of consciousness. This aids in identifying whether the patient is starting to emerge from a coma or a minimally conscious state.

The scale's lowest items signify reflexive activity, while the highest items represent cognitively mediated behavior. Patients' increasing awareness of their surroundings and stimuli is reflected in their responses, including reactions to pain stimuli such as a sternal rub or a pinch.

Scoring the CRS is standardized, and I highly recommend receiving training from a therapist, neuropsychologist, or someone experienced in CRS administration beforehand. Due to its nuanced nature, familiarity with all its steps and components is crucial before using it. The CRS is freely available (https://www.tbims.org/combi/crs/; http://www.coma.ulg.ac.be/images/crs_r.pdf).  It consists of 23 items organized into six subscales: auditory responses, visual responses, motor aura, motor communication, and arousal. These subscales are invaluable for tracking a patient's progress in treatment and the evaluation process.

Each subscale contains items arranged hierarchically, reflecting brain stem, subcortical, and cortical processes. As patients transition, you'll observe a shift toward more cortical engagement. Scoring is standardized, relying on the presence or absence of operationally defined behavioral responses to various stimuli. For instance, can they grasp a ball when it's rolled onto their hand? Pain responses play a significant role, as do oral motor reflexes (e.g., tonic bite). Observing whether reactions demonstrate more reflexive or cortical engagement guides treatment planning based on CRS results.

Additionally, the CRSR is a valuable tool for patient and family education. When families are coping with a loved one who has experienced severe injury and is gradually emerging from a coma, teaching them about the different components of the CRSR can foster a sense of involvement. While it's essential to ensure they don't become overly fixated or perform assessments excessively, this knowledge provides them with specific aspects to focus on. It empowers family members and maintains their engagement with the patient throughout the recovery process. Treating low-level patients is critical, and the CRSR offers an effective method for doing so.

Assessment: Rehabilitation

We've already discussed acute assessment, so let's move on to rehabilitation. Motivational interviewing can be highly effective, especially for patients who are capable of engaging in treatment. This approach is particularly beneficial for individuals at Rancho Level 5 and above or those with less severe stroke-related impairments.

Motivational interviewing serves as an effective starting point, allowing clinicians to identify their patients' strengths and weaknesses. By asking what aspect they would most like to improve, therapists can tailor interventions to be functional and specific. For example, if a patient struggles with remembering email passwords, exploring the circumstances surrounding this challenge, such as distractions or complicated technology, can provide valuable insights.

Throughout this dialogue, be empathetic and use your counseling skills effectively. Motivational interviewing facilitates a collaborative approach to rehabilitation, empowering patients to actively participate in their recovery journey.

By allowing the patient to choose what to focus on, you empower them to take ownership of their rehabilitation journey. This concept resonates with the scenario of an eight-year-old in school; you identify their interests and preferences, then tailor interventions accordingly. It's about aligning rehabilitation goals with the areas that matter most to the individual.

However, it's important to note that this approach relies on the patient having sufficient insight into their condition and an awareness of their areas of injury. It's most effective when the individual can recognize their impairment and express their priorities for improvement.

Assessment: Instruments

Here's a compilation of assessment instruments, including both screeners and comprehensive evaluations, which are valuable tools for evaluating various aspects of cognition. Let's start with screeners:

• The Montreal Cognitive Assessment (MOCA) is widely favored by hospitals and insurance systems due to its simplicity and standardization.
• The Repeatable Battery for Assessment of Neuropsychological Status (RBANS) offers a comprehensive assessment of cognitive function.
• The Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) can be challenging to administer due to its multiple components.
• The St. Louis University Mental Status Examination (SLUMS) and the Scales of Cognitive and Communicative Ability for Neurorehabilitation (SSCAN) are also effective for assessing cognition.

For an overall global cognitive assessment:

• The Woodcock-Johnson Psycho-Educational Battery provides a thorough evaluation, but it may be better suited for outpatient settings due to its intensity.

Assessing attention can be achieved with the following:

• The Attention Process Training Test and the Test of Everyday Attention.

Memory assessments can be done with:

• The Contextual Memory Test, Everyday Memory Questionnaire, and the Rivermead Behavioral Memory Test, the latter of which is particularly functional, involve tasks such as route-finding and object location recall.

For executive functioning:

• The Dallas Kaplan Executive Function System, Trail Making A and B, and the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) are recommended. It's essential to coordinate with neuropsychologists regarding tests like the Trail Making Tests and RBANS to ensure communication within the multidisciplinary team.

Acute TBI Case Example

Let's move on to a quick case study before discussing mild traumatic brain injury (mTBI). We have a 23-year-old Caucasian male who was an unrestrained driver involved in a motor vehicle accident resulting in a collision with a tree. At the scene, the patient was found unconscious with a Glasgow Coma Scale score of eight. Upon arrival at the emergency room, a CT scan revealed a large left subdural hematoma along with significant subarachnoid hemorrhage. Subsequently, the patient underwent a left frontal craniotomy and was placed on mechanical ventilation via oral intubation while stabilized in the ICU. The patient is now in your inpatient unit with a left frontal skull defect and is breathing room air.

Where do we start with evaluating this patient? Because these patients are so complex, we can address multiple areas of concern simultaneously. In this scenario, conducting a swallowing screen is essential, particularly in the inpatient acute care ICU setting. Additionally, assessing cognitive functions such as insight, attention, and orientation provides valuable insights into the patient's overall condition. These initial evaluations serve as critical starting points in managing the patient's care effectively.

Functional Evaluation and Specific Symptom Areas:
Mild Acquired Brain Injury

Transitioning out of the acute phase and into intensive outpatient, outpatient, or community reentry treatment or evaluation, the American Congress of Rehabilitation Medicine (ACRM) defines TBI as a physiological disruption of brain function resulting from a traumatic event. This disruption is evidenced by at least one of the following: alteration of mental state, loss of consciousness, loss of memory, or focal neurologic deficit, which may or may not be transient. However, the severity of the injury must not exceed certain parameters.

We discussed post-traumatic amnesia, where it persists for more than 24 hours after the initial 30 minutes. Additionally, the Glasgow Coma Scale score falls within the range of 13-15, which can be assessed using the GOAT tool. Loss of consciousness is limited to less than 30 minutes. These criteria collectively define mTBI according to ACRM.

While other medical groups may utilize different criteria, there's a general consensus on the definition of mTBI, which typically includes a Glasgow Coma Scale score of 13 to 15, brief loss of consciousness, brief PTA, and a negative head CT scan. This standardization facilitates a clearer understanding and classification of mild TBI across medical practices.

Concomitant Factors

In the realm of mTBI, there are many hot topics, with post-concussion syndrome being particularly notable due to its association with prolonged concussive symptoms. However, let's focus on some essential considerations.

When working with individuals who have experienced mTBI, they often present with concomitant factors beyond the injury itself. These factors may include psychological health comorbidities, moral injury (particularly relevant for service members or veterans), substance use disorders, and family stressors. For instance, a patient may be dealing with the aftermath of a divorce or managing the responsibilities of caring for multiple children, which can significantly impact their overall well-being.

Chronic pain is another significant factor to consider, as it can exacerbate cognitive stressors. Even in individuals without a brain injury, chronic pain can impair cognitive functioning. Therefore, it's essential to understand how these various factors interplay and how they may influence the overall evaluation results. Additionally, medications should also be on the radar, as they can impact both the presentation of symptoms and the effectiveness of treatment interventions.

mTBI and Cognitive Load

Understanding the concept of cognitive load is essential for comprehending the challenges faced by individuals post-mTBI. Essentially, when the brain is under cognitive stress, it may struggle to compensate for areas of weakness that it could manage before the injury. For instance, consider a patient with a baseline of ADHD who was previously able to compensate for distractibility. After sustaining an mTBI, they may experience exaggerated attention issues due to increased cognitive load.

Moreover, certain on-the-job activities, such as driving, can significantly contribute to cognitive fatigue due to their inherent complexity. Tasks involving memory, attention, pragmatics, and executive functioning all contribute to cognitive load. While these activities may have been manageable pre-injury, the additional cognitive demands post-mTBI can overwhelm the individual's capacity to cope effectively. 

It's so important to educate patients about this phenomenon so they can recognize when they're experiencing cognitive fatigue and understand the importance of rest. Encouraging patients to listen to their bodies and prioritize rest when needed can help mitigate the impact of cognitive load on their daily functioning and overall well-being.

Challenges with Using Formal Assessments in mTBI

One of the challenges when assessing mTBI is the limited sensitivity of formal assessments to detect subtle mTBI symptoms. While patients may appear normal across all domains on formal tests, they may still report experiencing difficulties in their daily activities. For instance, during a motivational interview, a patient might express frustration over no longer being able to complete their daily sudoku puzzle or other cognitive tasks they used to find easy. 

It's important for clinicians to be aware of this limitation and to consider alternative assessment approaches that may be more sensitive to mTBI deficits. Here are some examples of evaluations that can be utilized for various areas of deficit in individuals with mild TBI:

• Executive Functioning
  • Behavioral Assessment of Dysexecutive Syndrome (BADS)
  • Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
• Attention
  • Test of Everyday Attention (TEA)
  • Attention Process Training Test (APT)
• Memory
  • Rivermead Behavioural Memory Test (RBMT-III)
  • Word Finding/Language
  • Boston Naming Test
  • Subtests of the Woodcock Johnson III Tests of Cognitive Abilities
• Stuttering (Psychogenic or Neurogenic)
  • Stuttering Severity Instrument-IV (SSI-IV)

Functional Assessment

Incorporating memory tasks into assessment can provide valuable insights into a patient's cognitive functioning and ability to use memory strategies effectively. For example, asking a patient to recall five locations you provide can be a useful exercise. Depending on the patient's level of functioning, you can prompt them to use either internal or external memory strategies.

For instance, in a community reentry setting, you might task the patient with recalling locations like CVS, the local diner, a gas station, and two other places. If the complexity needs to be reduced, you can suggest external strategies such as writing the locations down or entering them into their phone.

Taking the patient into an unfamiliar environment and asking them to locate these places can further assess their memory, attention, and pragmatics skills. During this functional assessment, it's important to look for signs of anxiety or other psychological health issues that may impact performance and to communicate any concerns to the psychiatric team.

Adjusting the complexity of tasks based on the patient's abilities ensures that assessments are tailored to their specific needs and abilities, allowing for a more accurate evaluation of their functional status and cognitive abilities.

Holistic Assessment and Treatment

We want to ensure that your assessment focuses on function and ensures that patient-centered care is a foundational principle across all healthcare settings, whether in the ICU, during community reentry, or for outpatient treatment. The International Classification of Functioning, Disability, and Health (ICF) serves as a valuable framework for assessing and addressing health-related conditions in both children and adults. Developed by the World Health Organization, the ICF emphasizes a practice and person-centered approach to assessment and treatment planning.

Similarly, the Plan, Implement, and Evaluate (PI) framework provides a structured approach to treatment and goal planning.

Treatment and Goal Planning Frameworks

Goal setting is essential for both treatment and assessment, providing valuable insights into a patient's awareness and functional capacities. Here are some frameworks that can assist in guiding goal setting:

The International Classification of Functioning, Disability, and Health (ICF) offers a comprehensive framework that takes into account an individual's body function, level of activity functioning, and the impact of environmental factors on societal participation.

Another noteworthy framework is the PI (Plan, Implement, Evaluate) Model, developed by Dr. Solberg and Dr. Turkstra. This model emphasizes designing patient treatment plans based on their functional level, pre-existing goals, and body function. These treatment plans are then applied in customized environments tailored to the patient's requirements, with patient performance being assessed in both structured and unstructured contexts. This systematic approach ensures that treatment plans are tailored to the individual and are effective, aligning with their specific functional abilities and environmental circumstances.

Collaborative Goal Setting

Continuing on the topic of goal setting, it's essential to emphasize that this process should take place following formal assessment but prior to intervention. As I mentioned earlier, goal setting functions as a form of functional assessment and serves as a bridge between assessment and intervention. In this role, clinicians act as facilitators, guiding the discussion and employing techniques such as motivational interviewing to aid in goal establishment.

Additionally, goal attainment scaling can be a valuable tool in this process. Drawing upon your knowledge and experience, you can select evidence-based intervention strategies that align with the patient's goals and functional abilities. For individuals with mild traumatic brain injury who possess insight into their deficits, engaging in collaborative goal-setting can be particularly beneficial.

Functional Goals

Here are some examples of functional, long-term, and short-term goals:

1. Long-term goal: The patient will use memory strategies independently while in the work environment. Short-term goal: The patient will use circle location in conversation with familiar partners with 90% accuracy.

2. Long-term goal: The patient will safely consume the least restrictive diet to maintain nutrition and hydration. Short-term goal: The patient and clinician will collaborate to identify patient-centered goals for return to school.

Additionally, there are some other resources for functional goal setting. The ASHA website provides examples of how to apply the ICF framework to goal setting. Be creative and avoid a one-size-fits-all approach. Many electronic medical record systems allow you to develop templates for goal setting but make sure each goal is tailored to the individual patient's needs and preferences. This ensures that the treatment is truly patient-centered and maximizes the benefits for the patient.

Interdisciplinary Goals

When establishing interdisciplinary goals, it's important to maintain a patient-centered and functional approach. By focusing on the entirety of the patient rather than discipline-specific care, we can develop the most appropriate and effective treatment plans.

Consider the following examples of interdisciplinary goals: Let's say the overarching goal is "the patient will safely perform transfer from bed to wheelchair." From a speech pathology perspective, you might focus on ensuring the patient can recall and safely sequence the steps required for the transfer. Physical therapy would be concerned with the actual transfer and assessing the patient's level of functional independence using the FIM score. Occupational therapy may evaluate the use of adaptive equipment during the transfer.

In summary, emphasizing function is so important. Goal setting should be a collaborative process involving the patient, occurring after assessment and before intervention. It's essential to determine when to utilize formal assessment versus informal or functional observation. Functional assessment provides valuable insight into the patient's day-to-day functioning, guiding our treatment approach. Ultimately, our goal is to support the patient in achieving their desired level of function, aligning with both their own aspirations and those of their family.

Questions and Answers

Are you seeing any acquired TBI related to COVID-19?

I am not seeing it with acquired TBI, but I'm definitely seeing acquired brain injury through long Covid. And there's still a lot of research that needs to be done on what that looks like. It's a great question. I will admittedly say it is not my area of expertise. I have not had the opportunity to treat many patients with long Covid, but I've heard, at least from what I've read and what I've heard, it is really mirroring some of the more complex, mild TBI. So kind of that post-concussive syndrome type of presentation.

I have an eight-year-old student with a brain injury acquired during the birth process. She is nonverbal and uses an assistive technology device for basic communication, but is much more of a total communicator. She's under evaluation now, and we are trying to conduct a functional evaluation. Do you have suggestions for a thorough functional analysis for school?

If she uses her AT device and is more of a total communicator, I would try to set up situations where she can use her communication in different methods. Having her engage with peers and being able to observe her in a setting. I don't know how severe she is. I'm assuming that she's very severe, but I don't know if it is more communication-focused in severity or if there's also a cognitive component. But I would look at things like her day-to-day classroom tasks. How is she able to engage? How is she able to communicate? I would observe her in the classroom. I'm sure you're already doing that.  Maybe work with her family to see what activities she enjoys doing outside of school and engage her in those. Again, I don't know if she has any physical impairments, but engaging her in drawing or art or music and see how she can communicate through those tasks. So it's something that she would enjoy as well. So you're also building that relationship there.

Group evaluation is not allowed in many states. As therapists, we have to be mindful of doing things that complement the other disciplines but do not duplicate efforts.

That is correct. That kind of goes back to the insurance piece, too. Being in that sort of "dream setting" where the hospital system allowed the group intake, we were able to bill for it.