Acquired Brain Injury: Functional Treatment Across Settings

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

Learning Outcomes

After this course, participants will be able to:

• Describe key components of the International Classification of Functioning, Disability, and Health (ICF) and the Plan, Implement, and Evaluate (PIE)framework.
• List three functional therapy tasks to use in the acute rehabilitation setting for various cognitive and physical deficits.
• Describe the benefits of co-treating and developing multidisciplinary goals in functional treatment of brain injury.

Mechanisms & Symptoms of ABI (Review)

To swiftly recap Part 1, we discussed the mechanisms and symptoms of acquired brain injury. Acquired brain injury encompasses multiple types, namely traumatic and non-traumatic.

Traumatic brain injury (TBI) includes various forms, such as blunt force trauma, penetrating injuries, and non-penetrating injuries. On the other hand, non-traumatic brain injury encompasses conditions like stroke or other neurological impairments, such as anoxia or hypoxia, and neurodegenerative diseases.

The severity of acquired brain injury is on a continuum, ranging from mild to severe. It's worth noting that this classification may change in the future, which presents an exciting prospect.

ABI Severity

The Rancho Los Amigos Scale, also known as the Rancho Scale, is a tool for assessing the severity of TBI. The Glasgow Coma Scale is also widely used for evaluating TBI severity. Additionally, the National Institutes of Health (NIH) developed a stroke scale specifically tailored for assessing the severity of strokes, as the other two scales may not be directly applicable to acquired brain injury.

"Typical" Symptoms of ABI

Moving on to typical symptoms of acquired brain injury, several common issues manifest. These include challenges with attention, memory, executive functioning, problem-solving, language, pragmatics, social skills, swallowing, and various physical symptoms like hemiparesis, visual impairments, or vestibular problems. 

I want to divide this course into two main sections. The first part will concentrate on acute care and treatment for low-level brain injuries as well as more severe cases. Subsequently, the latter part will focus on the treatment of mild traumatic brain injury (mTBI). We will explore these symptom areas according to severity, providing examples of goals and outlining specific functional treatments applicable across different severity levels. This is a continuation of our exploration into acquired brain injury symptoms and treatment strategies.

Overview of Symptoms

An article by Mashima and colleagues (2021) provides valuable insights into somatosensory symptoms associated with acquired brain injury. These symptoms encompass a range of issues such as headaches, light sensitivity, visual disturbances, sleep disturbances—which are particularly prevalent post-injury—pain, fatigue, tinnitus, and dizziness.

Emotional symptoms are also common following acquired brain injury, including anxiety, increased irritability, susceptibility to anger or frustration, impulsivity, diminished energy or motivation, and depression. These emotional aspects are intertwined with cognitive symptoms discussed earlier, which encompass poor concentration, easy distractibility, memory deficits, slowed processing speed, organizational challenges, difficulty multitasking, and impaired decision-making abilities.

Post-Traumatic Amnesia

Post-Traumatic Amnesia (PTA) manifests in two distinct types. Retrograde PTA involves partial or total memory loss concerning events immediately preceding the brain injury. Typically, the duration of retrograde amnesia diminishes progressively over time, allowing for improved recollection closer to the injury's occurrence.

Conversely, anterograde amnesia refers to the inability to form new memories post-injury, leading to difficulties in memory retention and attention. Without the capacity to create new memories, individuals may struggle to learn new strategies, recall names, or understand their surroundings, hindering orientation. Anterograde memory often returns last during recovery from loss of consciousness.

The duration of PTA can range from minutes to months, correlating directly with long-term outcomes. Generally, a longer PTA duration indicates a less favorable prognosis, especially when coupled with severe brain injury.

Declarative memory, crucial for forming new memories, is impaired, while implicit and procedural memory remains intact. Thus, routine tasks like tying shoelaces or brushing teeth are typically unaffected. However, remembering new information, such as a nurse's name or orientation details, may pose challenges.

PTA significantly affects the ability to teach new strategies or compensate for deficits, as new learning is impeded until PTA resolves. Formal assessments, such as the Galveston Orientation Amnesia Test (GOAT), play a vital role in evaluating PTA by addressing orientation components—where, when, who, and what happened—in a structured manner.

Tenets of Intervention

Some basic tenets of intervention can guide treatment across various severity levels of brain injury. Establishing measurable goals is paramount, regardless of severity, and there are several methods to achieve this.

The ABCD method—focusing on Audience, Behavior, Condition, and Degree—is a classic approach for goal establishment. Similarly, the SMART goal system emphasizes goals that are Specific, Measurable, Achievable, Realistic, and Timely, providing a structured framework for goal setting. Goal Attainment Scaling (GAS) is particularly effective for milder brain injuries or post-concussion symptoms. GAS involves individualized goal selection and scaling, allowing patients to actively participate in goal setting, fostering rapport and buy-in. Each goal is rated on a five-point scale, facilitating standardized measurement of goal attainment.

Another essential aspect is systematic instruction, which involves coaching patients through routine practice and offering specific, immediate, and regular feedback. This feedback is crucial, especially for patients with severe or moderate injuries, aiding their progress even when memory formation is impaired during PTA. Empowering patients to become active participants in their own treatment is key. By teaching strategies and encouraging self-assessment and adaptation, patients learn to manage their condition independently, ultimately fostering autonomy and self-sufficiency.

Monitoring progress involves evaluating the effectiveness of implemented strategies and the patient's ability to develop and employ new ones. Assessing success and identifying areas for improvement are essential components of this process, particularly in enhancing executive functioning skills.

Ultimately, the goal is to equip patients with the tools and skills necessary to manage their condition effectively, thus working towards self-sufficiency and reducing dependence on clinical intervention. This proactive approach maximizes therapeutic outcomes and fosters long-term independence and quality of life for individuals recovering from brain injury.

Team Approach

In a typical rehabilitation program for individuals in the acute or post-acute stage, you'll commonly encounter various professionals addressing different aspects of recovery.

Physical therapists play a critical role in enhancing strength, endurance, safety, and balance and addressing vestibular issues.

Occupational therapists concentrate on Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), while collaboration between occupational therapists and SLPs may involve joint treatment targeting executive functioning or overall functional abilities.

SLPs play a multifaceted role in rehabilitation, addressing various aspects such as executive function, communication, swallowing, and cognition. Recreational therapists focus on social skills, pragmatics, and mental health, while social services or case management provide essential support. Primary care professionals attend to medical, dental, vision, and hearing needs, ensuring holistic care for the patient.

Additionally, the patient and their family are integral members of the therapy team, providing valuable input and support throughout the rehabilitation process.

While the composition of therapy teams may vary depending on the program, additional members such as nutritionists and neuropsychologists might be included to augment services. Each team member brings unique expertise, contributing to a comprehensive and collaborative approach to treatment.

Things to Consider When You're Treating

When treating individuals with acquired brain injury, several important factors must be considered to tailor interventions effectively.

First, medication management is vital. Understanding the medications the patient is taking, such as blood pressure medication or pain relievers, is critical as they can impact function and treatment effectiveness, especially if they cause sedation.

Another critical consideration is the patient's level of consciousness. Whether the patient is comatose, minimally conscious, or transitioning to a higher level of awareness greatly influences treatment goals and expectations.

Physical symptoms, such as mobility issues or hemiparesis, significantly impact rehabilitation plans, particularly concerning community reentry efforts. 

Communication abilities are paramount. Identifying if the patient is aphasic or experiencing word-finding difficulties informs strategies for facilitating effective communication, whether through assistive devices, speech, or other means.

Understanding family dynamics is essential, as family support and dynamics play a significant role in the patient's recovery journey. Collaborating with social workers, case managers, and the psych team helps gain insights into family dynamics and provides additional support resources for the patient and their family.

Considering these factors ensures a comprehensive and patient-centered approach to treatment, addressing individual needs and optimizing rehabilitation outcomes.

Agitation and Motor Restlessness

It's important to assess whether the patient's agitation is merely motor restlessness or if it poses a genuine safety concern. Understanding the underlying cause of agitation helps tailor appropriate interventions and ensure the safety of both the patient and the treatment team. Additionally, as previously mentioned, PTA is a significant consideration in treatment planning, impacting memory formation and cognitive function.

Treatment and Goal Planning Framework

Adhering to a functional approach is essential when evaluating and setting goals. This approach aligns with the International Classification of Functioning, Disability, and Health (ICF) and the Participation, Environment, and Performance (PEP) model. Each aspect of assessment and intervention should revolve around real-life functionality rather than rely solely on worksheets or flashcards.

Understanding the patient's interests and previous activities is key, even if they are unable to verbalize them directly. Collaborating with family and caregivers can provide invaluable insights into the patient's preferences and abilities. As the severity of the injury decreases, patients with mild TBI may become more vocal about their treatment goals. This engagement can be leveraged to utilize goal attainment scaling, fostering a collaborative approach to goal setting and enhancing patient motivation and engagement in therapy.

Let's move on to the ICF and PIE frameworks. The ICF delineates functioning into three main components: body functions and structures, activities, and participation. It also considers environmental factors that can influence a person's functioning and participation in society.

The Participation, Environment, and Performance (PIE) framework emphasizes a structured plan tailored to the patient's individual needs and functioning level. This plan integrates pre-morbid goals, considering what the patient aimed to achieve before their injury, alongside current body function assessments.

Implementation of the treatment plan occurs within patient-customized environments, utilizing functional strategies that align with real-life situations. This approach ensures that interventions are relevant and applicable to the patient's daily life. Through the PIE framework, the focus remains on optimizing participation and performance by addressing physical and cognitive functioning within the context of the patient's environment.

Collaborative Goal Setting

Goal setting should be done with patients or their families if the patients cannot participate in the process. This should occur after the assessment but before any interventions, with the clinician acting as a facilitator. The clinician's role is to use their knowledge and experience to choose the appropriate evidence-based intervention strategy. That's our job—to know what's best for our patients.

Going back to functionality, this approach is especially beneficial for patients with mild TBI and those who are aware of their deficits. Not being aware can lead to frustration for everyone involved.

Functional Goals

Here are some examples of functional goals to consider. These goals are typically long-term and focus on practical outcomes.

• Patient will use memory strategies independently while in the work environment.
• Patient will safely consume least restrictive diet to maintain nutrition and hydration.

As noted, these are longer-term goals that require a certain level of functioning. For shorter-term goals, you're looking at more specific metrics.

• Patient will use circumlocution in conversation with familiar partners with 90% accuracy.
• Patient and clinician will collaborate to identify patient-centered goals for return to school.

These goals are specific and measurable, allowing you to track progress, and are functional because they focus on meaningful activities rather than traditional therapeutic tasks like worksheets or memory games.

The ASHA website provides additional resources on functional goal-setting. It includes examples of applying the ICF framework to goal-setting and helpful links and ideas for creating patient-centered goals. 

When setting goals, being creative and avoiding a one-size-fits-all approach is essential. Each patient is unique; as the saying goes, "If you've seen one brain injury, you've seen one brain injury." Involve patients and their families in the goal-setting process to ensure the goals are meaningful and centered on the patient's needs.

Interdisciplinary Goals

Interdisciplinary goals are essential to a patient-centered, holistic approach to care. This approach encourages collaboration among various healthcare professionals, focusing on the whole patient rather than individual disciplines. It's about breaking down the silos and ensuring that every aspect of the patient's well-being is addressed.

Let's consider a common interdisciplinary goal: "The patient will safely transfer from bed to wheelchair." Each discipline plays a unique role in achieving this goal. Here's how they might approach it:

As an SLP, you're interested in the patient's cognitive and communication skills. For this interdisciplinary goal, you might focus on whether the patient can remember and sequence the steps for a safe transfer. A specific goal might be: "The patient will recall and safely sequence the steps to transfer from bed to wheelchair using nonverbal cues." 

The physical therapist's role is to ensure the patient can safely perform the transfer. They might set a goal like: "The patient will safely perform the transfer from bed to wheelchair with minimal assistance."

The occupational therapist is concerned with how the patient uses adaptive equipment and techniques to accomplish tasks. They might create a goal such as: "The patient will use adaptive equipment to complete the bed-to-wheelchair transfer with moderate independence."

Each discipline contributes to the overarching goal of safe transfers but does so from its unique perspective, focusing on different aspects of patient care. This collaborative approach ensures that all aspects of the patient's needs are met, from physical safety to cognitive ability and adaptive strategies.

Functional Treatment and Specific Symptom Areas:
Low-Level and Acute Brain Injury

When it comes to treating patients with low-level or acute brain injuries, it's essential to recognize that these patients can and should be treated. Even though they may be less responsive or present with more severe symptoms, there are effective ways to engage with them therapeutically. It's understandable for clinicians to feel apprehensive or unsure about the impact of their treatment, wondering if they're making a difference or potentially causing harm.

JFK Coma Recovery Scale (CRS)-Revised

The JFK Coma Recovery Scale is an excellent tool for assessing and treating patients at Rancho levels one to three. It evaluates auditory, visual, motor, oromotor, communication, and arousal functions, providing a comprehensive baseline to guide treatment and monitor progress as patients potentially move to higher levels on the Rancho scale. 

Originally released in 1991 and revised in 2004, the scale offers valuable prognostic insights and supports therapeutic planning. You can use it to assess key functions and measure improvement over time. For instance, when examining visual abilities, you might start with tracking. Initially, a patient might not follow your finger at all, but with progress, they might begin to track and eventually respond to simple commands.

It's quite rewarding to see patients improve and achieve higher scores on the JFK Coma Recovery Scale. Another significant benefit of the scale is its usefulness in educating families. By teaching them about the scale, you can empower them to engage with their loved ones during these early stages and acute phases, providing them with meaningful ways to contribute to the recovery process.

Additionally, it's important to note that the JFK Coma Recovery Scale is a standardized assessment, ensuring consistent and reliable results across different users and settings.

Treatment Ideas for LLBI Patients

As mentioned earlier, your treatment plan is based on the JFK Coma Recovery Scale. You'll be looking for signs of arousal and responses to simple commands. Be direct—avoid asking questions like, "Can you show me a thumbs up?" Instead, give clear instructions like, "Show me a thumbs up." This approach is more effective in these cases.

You'll also track eye movements and gaze, observing how well the patient follows moving objects. Another aspect of treatment is object identification and use. For example, you might show a toothbrush and ask them to demonstrate its use. This helps assess recognition and basic motor skills.

Part of your role includes educating the patient's family and caregivers about the treatment plan and the expected progression. This education helps them understand the process and prepares them to support the patient through recovery.

If you're trained in myofascial release or similar techniques, it can be helpful for treating lower-level patients, especially those with tonic bite. This approach can help relax tight muscles and ease tension.

Co-treating is another effective strategy for low-level brain injury patients. Collaborating with OT and PT while the patient is prone on a mat or wedge can be beneficial. This position can promote vocalization due to the diaphragmatic support provided by the wedge and the slight discomfort it can create, which encourages the patient to engage vocally.

Can they express discomfort or pain? Even if a patient is in an altered state of consciousness, they might still be able to hear you. I want to reinforce a key point: never talk about a patient in front of them or their family as if they aren't there. It can be demeaning and disrespectful. This applies even when patients are nonverbal or minimally responsive.

Not too long ago, I had a particularly sad experience with a patient who had suffered an anoxic brain injury. I was working with her when a physician walked in and started discussing her condition with me in a surprisingly casual and insensitive manner. The physician said something like, "Oh, this is such a sad case. There's really not much there." Before I could respond, she left the room.

I looked down at my patient and saw a single tear rolling down her cheek. It was clear that she had heard what the physician had said about her prognosis and how tragic her situation was. The physician didn't give me a chance to explain that the patient had just shown signs of command-following.

This situation serves as a reminder to all of us in patient care: even when patients are in an altered state of consciousness, we must assume they can hear us and always speak with respect and empathy. It's crucial to remember that our words can impact them deeply.

Shifting gears, another excellent treatment idea for low-level brain injury patients, focuses on oral care. This approach benefits the patient and provides an opportunity for family education. You can show families how to perform oral care, including using suction devices, and discuss the risks associated with aspiration. This is also a good time to emphasize the importance of oral hygiene and how it contributes to the patient's overall health.

Refresher: PTA

How does PTA impact assessment, treatment activities, and goals? If patients are unable to form new memories, treatment can be challenging as they may struggle to remember compensatory strategies or other techniques. Let's explore this further by discussing the different areas of concern.

Memory

Memory treatment goals should be functional and patient-driven. Let’s take a closer look at the different types of memory to understand where your focus should be.

First, there's prospective memory, which involves remembering to perform a task in the future, like taking medication or attending an appointment.

Then there's short-term memory, which refers to retaining information over a short period. This type of memory is crucial for day-to-day activities and conversations.

Working memory functions like a mental scratch pad. It's where you manipulate information temporarily before discarding it. For example, if you're doing math in your head or recalling a phone number before writing it down, you're using working memory. Similarly, when you cram for a test and forget everything shortly after, that's also working memory in action.

Long-term memory can be divided into explicit and implicit categories. Explicit memory requires conscious thought to recall specific information, like a song's title or a family member's birthday. It involves the intentional retrieval of facts, events, or concepts. Implicit memory, on the other hand, doesn't require conscious effort to recall. This is where procedural memory comes in—it encompasses the skills and tasks we do automatically. It's typically not affected during post-traumatic amnesia. Procedural memory includes activities like tying your shoes, brushing your teeth, or climbing stairs. These tasks become second nature, so we don't have to think about each step while doing them.

Here are some examples of memory-focused goals for SLPs in an acute care rehab setting:

• "Patient will recall the names of primary therapists with moderate visual and verbal cues." This goal is designed to gauge the patient's ability to remember key people involved in their care. For example, can they recognize a therapist's name tag or use a daily schedule to identify their therapist?

• "Patient will route to their room using environmental cues with maximal verbal cues." This goal assesses the patient's ability to navigate within the rehab unit. It involves recognizing landmarks or following signs to find their way back to their room. This can be crucial in assessing their orientation and ability to use environmental cues to guide their movements.

These goals are aligned with an acute care rehab program, where multiple therapists and professionals interact with the patient. The goals focus on practical skills that require memory and environmental awareness, helping patients work toward greater independence in their everyday activities.

Here are some examples of co-treating between a PT and an SLP with a focus on memory:

• "Patient will recall the steps to safely transfer from bed to walker with minimal verbal cues." As the SLP, you can support this by taking photos of each step in the transfer process, printing them, and using them to guide the patient. At the beginning of the session, you might review the photos with the patient, asking them to sequence the steps. This reinforces memory through visual cues while also providing a practical guide for the actual physical transfer, which you can then work on with your PT partner.

More SLP Functional Memory Tasks

"The patient will write down their schedule every morning." In a rehab setting, patients often have full days of therapy. This task helps them take ownership of their schedule by either writing it down or adding it to their phone calendar. We can use assistive technology to support memory.

"The patient will identify their medications and understand their purpose at each administration." This is crucial, especially for patients preparing to leave inpatient treatment. They need to know their medication names, appearances, dosages, and correct administration times. This understanding is vital for safety and medication compliance. You can incorporate various activities to reinforce medication knowledge.

"The patient will recall compensatory strategies for dressing the lower extremity." This task aligns with the transfer goal mentioned earlier. Work with your OT partner to identify the dressing steps they've been teaching. Then, you can help the patient with sequencing and recalling these steps, supporting their progression toward greater independence.

Attention

There are several types of attention. The most basic is focused attention, where you respond to a specific stimulus, such as pain or cold. An example is the reaction to a sternal rub or other painful stimuli.

Next is sustained attention, which is about maintaining focus over a longer period. This is also known as vigilance, where you keep your attention on one thing for an extended duration. Examples include studying for a test or completing a PowerPoint presentation.

An analogy to illustrate sustained attention is in a military context. For active-duty service members, especially snipers, the ability to maintain focus on a target for an extended time is extremely important.

Selective attention is the ability to focus on a single task or stimulus amid other distractions. For example, reading a book while the TV is on or taking a phone call while people are talking around you. This type of attention is critical in our daily lives, given the constant stream of stimuli we encounter.

Alternating attention refers to the capacity to switch focus between different tasks. For instance, if you're writing an email and the phone rings, you can answer the call and then return to your email without losing track of your original task.

Lastly, there's divided attention, which involves attending to multiple tasks simultaneously. This concept has sparked debate among experts, as some suggest that what we perceive as divided attention is actually rapid task-switching. A common example is driving: you're monitoring your speed, controlling the brake and gas pedals, listening to the radio, interacting with passengers, and watching other vehicles on the road—all at the same time. Driving demands continuous attention to multiple factors, illustrating how complex divided attention can be.

Functional Attention Treatment Tasks

Here are some examples of functional attention treatment tasks:

• "Patient will attend to a 15-minute treatment session with moderate verbal cues." This task assesses the patient's ability to maintain focus over a specific period, helping you measure their sustained attention.

• "Patient will attend to safety signs on the unit while routing to their room with minimal verbal cues." This task involves focusing on specific visual cues, such as fire extinguishers or exit signs while navigating through the unit. It’s a useful way to encourage awareness and safety during patient mobility.

• "Patient will prepare a hot meal for three fellow patients with moderate verbal cues to maintain attention and sequencing." This task is an excellent example of a co-treatment involving OT and SLP. It requires attention to detail, task sequencing, and sustained focus, all of which are critical components of functional therapy.

Executive Functioning

Patients with executive dysfunction often have trouble planning and organizing tasks, initiating actions, and seeing them through to completion. This might manifest as difficulty identifying a problem, creating a plan to solve it, executing that plan, and then evaluating the outcome. A key aspect of executive dysfunction is reduced impulse control, leading to a lack of filter. These patients tend to share some of the most intriguing stories because they often speak their minds without hesitation, sometimes exhibiting socially inappropriate behavior due to decreased insight.

Successful executive functioning requires sustained attention, as patients need to stay focused on a task long enough to complete it. It also relies on working memory to hold and manipulate information while following through with a plan. Additionally, effective executive functioning involves social skills, particularly in terms of inhibiting inappropriate responses or behaviors.

Functional Treatment Tasks for Executive Functioning

Here are some functional treatment tasks for executive functioning:

• Goal Setting and Planning: Engaging patients in setting their own goals and planning their treatment is a great way to promote insight and awareness. This approach fosters a patient-centered focus, builds rapport, and motivates participation in treatment.

• Scavenger Hunt Around the Unit: This activity assesses a patient's ability to plan, follow directions, and stay organized. Ask them to find exit signs, fire extinguishers, their friend's room, or their favorite nurse. This exercise requires problem-solving and spatial awareness while adding an element of fun.

• Meal Planning and Grocery Store Outings: Collaborating with recreational therapy, physical therapy, or occupational therapy, patients can work on planning a meal for a small group. This includes sequencing the steps to prepare the meal, creating a grocery list, and planning the route to the store. They can also estimate the cost of items to develop budgeting skills.

These tasks aren't just for assessing executive functioning; they also involve memory, problem-solving, and social skills. The benefit of these activities is that they're highly functional, focusing on real-world applications. They're more engaging than traditional worksheets or isolated exercises, providing patients with valuable opportunities to practice and improve their skills in meaningful ways.

Speech and Language

Structured conversations with fellow patients, staff, and family members are another great way to assess and improve executive functioning and social skills in an inpatient setting. As mentioned earlier, orientation groups are one option, but you can also create other types of social groups where conversation is structured around specific tasks or interactions.

One approach is to have the patient request items from staff. For example, you might ask your patient to request their 3:45 PM medication from a nurse. This task provides insight into several areas: Do they remember which staff member to approach? Do they recall the specific medication to ask for? This also allows you to observe their communication skills, such as word-finding, articulation, and fluency.

For nonverbal patients, you can evaluate the use of compensatory strategies, like communication boards, phone texting, or writing notes. These methods can help nonverbal patients express their needs and interact with others. Additionally, you can assess speech and language skills by examining the patient's intelligibility in both structured and non-structured environments.

As with any speech and language treatment, you typically start with the most structured tasks and gradually move to more unstructured ones. The goal is to evaluate how intelligibility changes as the environment becomes more chaotic and less predictable. You should also observe the patient's speech and language abilities in various settings, not just in the therapy room, to get a complete picture of their functional communication skills.

Speech and language tasks are ideal for co-treatment because communication is involved in nearly every activity. Any therapy session that requires verbal interaction can be adapted to work on speech and language goals.

For example, when walking with a PT, you can work on the patient's intelligibility strategies throughout the session. Even if you're not present during the PT session, you can ask your PT colleague to encourage the patient to slow their speech rate and use circumlocution when they struggle to find the right word.

In an OT co-treatment, you might assist in bathing the patient, asking them to name items in the shower. This is a simple yet functional task that incorporates everyday activities into speech and language therapy.

During a community outing with recreational therapy, you can ask the patient to order food items for themselves or other patients, focusing on pragmatic skills and social interaction. This type of activity allows you to evaluate the patient's communication skills in a real-world setting.

Case Study: Acute ABI

A 23-year-old caucasian male, unrestrained driver, status post MBA car versus tree, arrived unconscious and presented at a GCS 8 upon arrival at the emergency room. CT revealed a large left subdural hematoma and a substantial subarachnoid hemorrhage. A left frontal craniotomy was performed, and the patient was mechanically ventilated via oral intubation.  While stabilized in the ICU, the patient presents to your inpatient unit with a left frontal skull defect and breathing room air.

What are some of the physical symptoms we are likely to see? With a left skull defect and frontal lobe injury, you’ll likely see right upper and lower extremity hemiparesis, speech and language issues, and potentially aphasia. Due to the left frontal lobe involvement, pragmatic issues might also be present. Dysarthria could occur, impacting speech clarity, and cognitive issues may emerge, such as memory, attention, and problem-solving difficulties. Executive functioning could be affected, and swallowing issues might also be a concern.

Where do you focus first? In this situation, I'd usually start with swallowing—doing a bedside swallow evaluation to ensure the patient can safely swallow food and liquids without risk of aspiration. After that, I would assess cognition and speech and language. Since you can address these areas simultaneously, you can focus on functional tasks that combine different aspects of care.

Given that swallowing is critical for nutrition and safety, it's the top priority. Once you confirm the patient is swallowing safely, you can dive deeper into cognition and communication. But remember, you can often work on these skills at the same time by incorporating functional activities that engage multiple aspects of therapy. 

Specific symptom areas for mild TBI include empowering patients and fostering resilience. This involves educating them about their expected recovery and the potential impact of comorbid conditions on cognition and function. It’s essential to assess whether they are sleeping well, experiencing chronic pain, taking medications, or dealing with psychological health overlays. Explaining how these factors can affect their symptoms and recovery helps patients understand their situation better.

Mild TBI patients usually have some level of awareness of their injury and its effects. Your role is to build rapport and motivate them to engage in treatment, aiming to restore pre-morbid cognitive and communication function when possible. Validation of their symptoms is key. Even if formal tests don't show significant issues, such as a Boston Naming Test coming out normal, it's important to acknowledge their experiences. This approach builds trust and encourages them to work on compensatory strategies for memory or word-finding issues.

It's not about promoting malingering; it’s about validating their concerns. Discussing the importance of routines and rest is critical, but avoiding excessive rest is equally important. Mild TBI recovery requires a balanced approach, ensuring that the patient gradually resumes activities without overexertion. Symptom mitigation strategies should include encouraging regular exercise, maintaining proper nutrition, and following medication regimens.

Role of the SLP

As an SLP, your role in cognitive treatment involves addressing a range of symptoms. We've covered many of these areas, but for lower-level brain injuries, the focus often centers on the information processing model. This model is based on the idea that attention is the gateway to all other cognitive processes. If patients struggle with attention, it affects their ability to form memories, solve problems, and complete tasks effectively.

Decreased attention often leads to reduced memory, causing cognitive fatigue. This fatigue can push patients to overexert, resulting in physical symptoms like headaches, stress, and poor sleep. It's a constant cycle. With this in mind, we want to structure treatment based on the information processing model, focusing on improving attention to break the cycle and allow for better cognitive function.

Guiding Principles of Therapeutic Intervention

• Recruit resilience
  • Ability of the patient to apply core values to handle stress and overcome adversity
  • Ask the patient to name their source of strength
• Cultivate therapeutic alliance
  • Provides the foundation for the therapeutic relationship
  • Goal is to ultimately transfer responsibility of goal achievement to the patient
• Acknowledge multifactorial complexities
  • Headache, pain, sleep, depression, psychological health disorders
• Build a team
  • Include family members and other therapeutic partners on team; all partners need to be in sync
• Focus on function
  • Understand the patient’s strengths, resources, impairments, and comorbid factors impacting daily function
• Promote realistic expectations of recovery
  • Positive, realistic expectations by providing education about recovery and highlighting strengths and weaknesses

Recruiting resilience involves tapping into the patient's inner strength and past experiences to inspire and motivate them during treatment. Ask your patient to share a time when they faced a significant challenge. For example, you might say, "Talk to me about a time when you went through something really difficult."

Suppose the patient mentions training for a marathon. You can respond, "Wow, that must have been really challenging. What did you rely on to stay motivated to complete that marathon?" If they mention listening to pump-up music during long runs, that's a clue to their resilience.

You can then reinforce their strengths: "You are a resilient person. You overcame that marathon. If you can do that, you can get through this." This positive reinforcement helps build a therapeutic alliance between you and the patient. 

Acknowledging all the complexities, like psychological health, nutrition, chronic pain, and sleep issues, is crucial. As we discussed, it's about building a comprehensive team that addresses each aspect of the patient's recovery. This approach is equally vital for patients with mild TBI. When you establish a strong team and focus on function, it helps the patient stay on track.

Promoting realistic expectations of recovery is essential. While it's important to encourage resilience and motivate patients, setting achievable goals and providing clear guidance can help them stay grounded.

Memory

What did your patient use for memory compensation prior to injury? It’s an essential question because everyone has their own compensatory strategies for memory. I use my phone to set reminders, keep a written notebook, and check off lists throughout the day. Understanding what your patient used before their injury helps you tailor treatment goals.

The treatment goals should depend on the patient’s functional needs and future aspirations. For example, does your patient want to return to school? Is your patient in the military and want to return to the same job?

Memory Compensatory Strategies. These strategies are usually where people start when addressing memory challenges. You can teach internal and external compensatory strategies to help patients improve their memory.

Internal strategies include techniques like acronyms, association, mnemonics, visualization, repetition, routines, and chunking. These methods rely on cognitive techniques to enhance memory. 

External strategies involve using technology or tangible aids. This includes using phones and apps, writing things down, setting visual cues, creating lists, or sending voice messages to yourself. For example, I had a patient who always forgot things on his way out the door. He and his wife solved this by hanging a whiteboard in front of his car in the garage, listing essential items like keys, ID badge, boots, etc. Before leaving, he would check the board, ensuring he had everything he needed. This is a practical example of an external compensatory memory strategy.

Routines are also crucial. A common routine is the "pat down," where you check for your wallet, keys, and badge before leaving the house. These structured habits can help reduce memory lapses and make daily activities more manageable.

Memory Treatment Ideas.  Here are some memory tasks to use in therapy. Ask the patient to email the therapist three different pieces of information at three separate times: their date of birth at 1:00, their last appointment of the day at 3:00, and their rank at 8:00 the following morning. This task assesses their ability to remember and act at specific times.  Ask the patient to brainstorm an external memory strategy for managing medication or recalling appointments. This could involve using a pillbox, setting phone alarms, or creating written reminders.  Have the patient read an article in the morning and then summarize the content to their partner or spouse at the end of the day. This task tests memory recall and communication.

Attention

We talked about the different types: 

• Focused
• Sustained
• Selective
• Alternating
• Divided

Different attention treatment ideas include Attention Process Training (APT) tasks, scavenger hunts, cancellation tasks, and reading in a distracting environment. Attention treatment often involves working memory because attention is the basis of information processing.

APT provides a graduated approach based on the patient's needs and complexity. It includes both assessment and treatment components, making it a versatile tool. 

Another example is reading while canceling specific letters, such as crossing out the letter "a" throughout the text, and still recalling the content. This exercise demonstrates selective attention, where you focus on one task while tracking another. These activities offer a functional approach to attention treatment.

Executive Functioning

Patients with executive functioning issues often exhibit a lack of filter. A common complaint from spouses is that these patients start multiple projects but never complete them. This can be incredibly frustrating for caregivers or partners, leading to situations like a bathroom with partially finished tile or baby locks on only half the cabinet doors. This inconsistency creates tension and might make caregivers feel like they have to nag to get things done.

Decreased insight, a common symptom of executive dysfunction, can also lead patients to believe they are ready to return to work or school before they actually are. This can create additional stress for caregivers and lead to setbacks if patients push themselves too soon.

Executive Functioning Treatment Ideas

Goal setting and planning can involve activities like scavenger hunts and functional memory tasks. When I worked with Navy SEALs, we would simulate the dual communications they experience in their headsets, where people talk to them in both ears. This approach mirrors the real-world scenarios they face. Another method is discussing home projects and involving the spouse to create plans for completing those projects.

Verbal Fluency/Word Finding

Many patients report mild word-finding difficulties, often described as a "tip-of-the-tongue" feeling where they struggle to retrieve a word. Standardized word-finding evaluations may not always detect these subtle deficits, so validating these symptoms is important. 

To work on word-finding, you can use strategies like visualization and alphabet scanning. When patients can't think of a word, they can mentally go through the alphabet to trigger recall. Circumlocution—talking around the word—is another helpful technique when the exact term eludes them.

Another effective treatment strategy is to have your patient brief their therapy team or present something to them. This could involve sharing their favorite activity, discussing a hobby, or talking about a favorite recipe. These exercises are excellent for building verbal fluency.

Stuttering

Stuttering is rare among mTBI patients, and there's an ongoing debate about the nature of stuttering following mTBI. However, some patients may exhibit stuttering-like characteristics. As mentioned earlier, observing patient' speech and language in the therapy room and in more functional settings is critical to understanding if stuttering is present and whether it affects their daily activities.

Stuttering Treatment Ideas

Stuttering treatment involves a typical course of action. You start with education on fluency strategies, helping patients understand techniques to manage stuttering. Then you progress through a hierarchy, beginning with the syllable level, advancing to word level, phrase level, then up to sentence level, and ultimately connected speech.

Summary of Functional Treatment Ideas

These suggestions address the various areas we've discussed. A scavenger hunt can be useful for improving attention, memory, and executive functioning. Reading tasks can target attention, memory, language, and executive functioning. Establishing routines is another effective strategy that touches on these critical areas.

When considering treatment planning for mTBI, it's important to address the patient's long-term goals. Do they want to return to work or go back to school? The key is to focus on function as you develop your treatment plan. This approach works for all levels of brain injury, from severe to mild TBI.

Questions and Answers

Can you elaborate on how you do a scavenger hunt around the unit?

For clients who are in acute rehab, you can have them look for things like fire extinguishers, exit signs, the nursing unit, and that kind of thing. So, that's a more basic one for mTBI. If you're in the community, it means the world is your oyster. You can have them find five different stores. If you're able to go out in the community, have them locate CVS, Walgreens, etc. While in those stores, have them find different items. You want to work on increasing or decreasing the complexity. You can have them find items in a certain aisle that add up to a certain amount of money. Again, it's great because you can increase or decrease complexity based on your patient's needs.

Sometimes, when patients have attentional issues, it may seem like they also have word-finding problems. But if you address word finding and don't address attention, they might not show that much improvement. Maybe the locus of the issue could be attention. Do you have any comments on that?

Attention is the basis of treatment, especially for this mTBI population. All these things overlap, especially in mTBI. So, addressing everything as much as you can is critical. That is a great point, and it's hard to separate things out discreetly.

Can anything be done to help the patient move through PTA?

Many programs offer an orientation group. You get your patients in a circle who are not yet oriented and review where they are, how they got here, what their names are, the city, the state, etc. There is debate about whether that works or not. If they're not able to form new memories, is an orientation group really going to help now? Of course, socialization is important. Interaction with other patients, as long as it's safe, is always positive. But being able to move somebody through PTA faster, unfortunately, there is nothing out there that I'm aware of in the literature that really shows a way to do that other than continuing to engage them in treatment.

How do you set goals with people who don't think they have a problem and are fine?

You'll find this a lot, and I'm sure you have many stories to share with patients who completely lack awareness with the executive dysfunction piece. It's very challenging. So, trying to convince them of their areas of deficit really depends on where they are psychologically.

So this would be another great time to talk with your psych team or neuropsychologist. If you have that ability to reach that person, to understand, how in their face should you be with their areas of deficit? I always start with reviewing their actual assessment results and showing them, "Hey, here it's saying that you're having problems with memory and attention. Here, it's saying you're having problems with attention. Do you ever feel like you aren't able to attend?"

But it's tricky. There are many different strategies, including education. You can co-treat with your psych professional team member by talking about different strategies. You could do more hypothetical or you could be the very upfront, "Here are all your areas of deficit,. Here's why you're in treatment. Why do you think you're here?"

But, again, it's really challenging in that case, so setting goals independently is sometimes the best way. One goal you can set with them anytime, even if they don't have awareness, is the patient education piece. 

Do you find it challenging to teach family members and caregivers how to help the patient? Do you have any tips in this area?

Yes, it really can be. I mentioned the family dynamics component earlier. Depending on what the dynamic was prior to injury, you have some families who are just grasping at control and want to control whatever they can because they are completely out of control, which makes total sense. But when that happens, it can be really challenging to teach them how to help and that they shouldn't be doing everything for their loved one. You need to actually support them in functioning as independently as possible.

To me, it all starts with education and with families. You can be blunt with families. Whereas, with patients, you need to be concerned about the psychological impact due to lack of insight, etc. With families, you can be blunt. You can say, here are the areas of deficit; here's what I need you to do. And then, of course, if it gets to the point where they can't be engaged in treatment, you dismiss them from treatment and ask that they not be present so you can continue to make the most progress.