Evaluation of Mild Traumatic Brain Injury

This text is a transcript of the webinar, Evaluation of Mild Traumatic Brain Injury, presented by Erin O. Mattingly, MA, CCC-SLP, CBIS.

Learning Outcomes

After this course, participants will be able to:

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

Etiology of mTBI

The highest rate of mild traumatic brain injury (mTBI) comes from falls, vehicle accidents via bikes, cars, and now, motor scooters.  I live in DC and they are everywhere. We got a bit of respite from scooters because of COVID. But before COVID, the motorized scooters in DC were causing increased rates of TBI at one of the major academic hospitals in town.  Violence, domestic violence, gunshot wounds, and shaken baby syndrome can cause a range of TBI from mild to severe. As well as sports injuries, concussion, and blast injuries in our service members and veterans.

Overview of mTBI Symptoms

The common symptoms are headache, fatigue, balance and vision issues, nausea, and vomiting.  These are the “physical” symptoms.  Within the vision issues, there might be some blurred vision too.

Cognitive-Communication Symptoms

In terms of the cognitive and communication symptoms tied to mild traumatic brain injury, there are issues in attention, memory, executive functioning, verbal fluency, and complex problem-solving. Sometimes, although it’s rare, stuttering can occur.  If it is present, it's tied more to the psychological aspect of something like post-concussive syndrome. I'll talk through that more later.

Attention

The main types of attention are: focused, sustained, selective, alternating, and divided.   This model is based on Sohlberg and Mateer's work.

Focused attention. This is the most basic form of attention. It's responding to pain or temperature. A patient in a coma is not going to respond to anything. But, somebody in a minimally conscious state can respond to pain.  (Keep in mind that a patient in a minimally conscious state is not considered to be mTBI. This is just an example of a severe head injury and focused attention.) So, even though that patient may not be responding to anything else, they're still responding to pain.

Sustained attention. This is your vigilance and ability to pay attention to one thing for a longer period of time. For example, studying for a test, completing a PowerPoint, paying attention during a webinar requires sustained attention.  When I worked with service members and veterans, an example that I would use for them is focusing on a target as a sniper.

Selective attention.  This is the ability to attend to a single thing amidst other distractions. For example, staying focused on reading while the TV is on, which is not something I do very well. But sometimes when I'm working from home, I like having background noise like music or the TV.  But selective attention is being able to attend to whatever you’re working on, even though there’s background noise.

Alternating attention. This is the idea of being able to turn your attention to various tasks. Here is an example.  An executive assistant is writing an email and the phone rings.  They answer the phone and then have the ability to return to their email without needing to remember what they were doing. They were immediately able to alternate their attention back to that task.

Divided attention. This is the ability to attend to multiple things at the same time. There's a debate about whether this is actually a thing. But for the purpose of this discussion, we'll refer to divided attention as the infamous "multitasking".We all know they say you can't really do anything well when you're doing multiple things at the same time.  An example of this is driving. When you're driving, you're focused on other passengers that may be in the car. You're focused on your speed. You're focused on the other cars around you. You might be focused on the radio or how much gas you have in your car. So, it's the ability to divide your attention and focus on more than one thing at a time. 

Memory

Prospective memory is memory for future events such as an upcoming appointment. Remembering that I have another webinar in two weeks is an example for me.  Short-term memory is the ability to remember information over a shorter period of time. Working memory is your "scratchpad" or the ability to manipulate information in your brain and then dump it. For example, doing addition in your head, the infamous “Serial Sevens”, recalling someone's phone number before you can write it down or put it in your phone, cramming for tests, etc. Those tasks can short-term and working memory.

Finally, long-term memory has several types.  There's implicit memory, which is more procedural. It does not require conscious memory and allows for rote activities. For example, tying your shoes, brushing your teeth, driving, riding a bike, climbing the stairs, etc.  Then there's explicit memory which requires conscious thought such as remembering the name of a song, a family member's birthday, or your anniversary.  These types of things actually require conscious thought, they're not as procedural.

Executive Functioning

Patients with mTBI present with difficulty planning and organizing, initiating tasks, and completing tasks.  Difficulty completing tasks is a huge issue in the mild TBI population. I often hear, "My husband or wife starts tasks and doesn't finish them." "I have lots of unfinished things around the house."  Patients may also have difficulty inhibiting responses. There's less of a filter and decreased insight when executive functioning is impaired. 

Executive functioning involves the ability to sustain attention on a single task, have working memory, as well as pragmatic skills. Executive dysfunction is very common, especially post-concussive syndrome or mild TBI.

Verbal Fluency

This is another area that is commonly affected in mTBI. Many patients report word-finding difficulties following mTBI, “tip of the tongue” syndrome in which the person just can't get the word out.

Something that's really important to talk about is that not all standardized word-finding evaluations will pick up some of the subtle word-finding changes that patients report. For example, if I'm administering the Boston Naming Test, the patient may score well above average on it even though they're reporting in their functional speech they're having difficulty finding words.

Stuttering

There is a debate about the nature of stuttering following mild traumatic brain injury. As I mentioned, sometimes it can be more psychological in nature. But patients can present with characteristics of stuttering. Therefore, it's important to observe the patient's speech and language, not only in the therapy room but also outside of the therapy room for functional communication.

According to the DSM-IV, the prevalence of stuttering is approximately 1%, with the majority of cases beginning in childhood. So, it’s very rare. Stuttering that begins in childhood is the developmental type of stuttering, with 80 to 90% of those occurrences occurring by age six.

Neurogenic stuttering, which is an acquired speech disorder, typically affecting adults following neurological disease, stroke, or TBI. This may be what you're seeing after mild traumatic brain injury in a patient with a stutter.

There is also psychogenic stuttering which is a behavior resulting from physical or emotional trauma or stress. It's usually a later onset disorder resulting from a change in neurological status. How we differentiate between neurogenic and psychogenic is a course in itself.  But, a rapid response to treatment is the main factor that differentiates between psychogenic and neurogenic stuttering.

I had a patient that presented with a stutter and I wanted to tease out whether it was neurogenic or psychogenic because he’d had multiple traumatic brain injuries.  When I presented him with a typical course of treatment, that hierarchical type of stuttering treatment starting at the syllable level all the way up to connected speech, he had a rapid progression to fluency. So, in working with the psychologist, we determined that it was a psychogenic stutter because he was completely fluent within two weeks of treatment. Again, true neurogenic stuttering post mild traumatic brain injury is fairly rare.

Sideline Evaluation of Sports Concussion

In this day and age, talking about mild TBI sports concussion is going to come up. Some of the methods that are being used right now are not be administering by an SLP on the sidelines. That might actually be the role of the athletic trainer or the coach. But it is still important to recognize that this is happening and we need to be aware of what it may or may not pick up.

It's challenging to diagnose sideline concussion because of a few factors:

1. Recognize symptoms rapidly postinjury
2. Adhere to objective assessments
3. Ensure patients remain out-of-play until diagnosis
4. Triage to further evaluation
5. Enforcing return-to-play (RTP) recommendation

The research suggests that it's challenging because recognizing symptoms rapidly post-injury can be a challenge.  For example, if you put yourself in a football game setting and you see somebody sustain a significant hit with a potential concussion, being able to recognize the symptoms immediately can be a challenge, especially for somebody who's not trained. You're looking for loss of consciousness. You're looking for headache, memory issues, and disorientation.

Additionally, adhering to objective assessments can be a challenge as well as ensuring patients remain out of play until diagnosis.  If somebody on the sideline notices that there might have been a concussion, they pull that player out and make sure that they don't return to play before a formal diagnosis.  The ability to triage to further evaluation ties right into that, as does enforcing a return-to-play recommendation.

When do they return to play?  Really, that's what the challenge is. We have to make sure that folks are getting the protection that they need post-concussion, especially when you're dealing with some sports injuries where the athletes want to go back in to play.

Some tools that are used on the sidelines include:

• The Sports Concussion Assessment Tool (SCAT), which is the most validated and neutralized assessment. However, training is needed in order to administer it.  It's not something that you can just look at and follow easily.
• The King-Devick Test should be used in a combination with the SCAT. It's not used in isolation.

Again, the challenge for both of these tools is that training is needed and the availability of baseline information.  Just like anything else, if you don't have a baseline, it's really difficult to assess the impact of the concussion or mild traumatic brain injury.

The benefits of the SCAT include a score interpretation that can trigger the removal from play in order to minimize the subjective interpretation by the examiner. I previously mentioned the difficulty of having an objective evaluation because it is so subjective to report an athlete's headache or vision disturbance or memory issues. But the SCAT is more of an objective assessment that can trigger an athlete’s removal from play.

The assessment is sensitive and specific, and the inter-rater reliability has been studied extensively. However, because of the training needed, it requires trained medical personnel to detect meaningful changes, which is a challenge of the SCAT. 

The King-Devick Test actually assesses visual systems and measures the speed at which athletes read 120 numbers from three test cards.  The final score is the sum of the total time reading the cards and the number of errors. Again, it's an instrument that enhances the concussion detection of the SCAT and should only be used in conjunction with the SCAT or other neurocognitive testing because the King-Devick mainly focuses on the visual aspects.

Sideline Evaluation: Additional Research

There are some newer tools that are tied to sideline evaluation of concussion. The Vestibulo-Ocular Screening and Eye Tracking, or the VOMS, assesses vestibular symptoms that include blurred or unstable vision, nausea, vertigo, dizziness, and discomfort in busy settings. That's the vestibular component of it. The ocular motor component looks at blurred vision, diplopia (i.e. double vision), headaches, eye strain, dizziness, nausea, difficulty tracking a moving target, and scanning for visual information. Additionally, it demonstrates accuracy in determining concussion within days post-injury. But more research is needed in regards to efficacy in immediate post-injury. So, it helps determine concussion within days post-injury, but not necessarily immediately. This is another evaluation tool that requires training for the interpretation of the scores.

You may have heard of Head Impact Sensors in the NFL.  This is through Head Impact Telemetry Systems. These sensors are also on the helmets that our service members use.  It measures significant variations in rotational concussive injury across athletes. However, it really only measures the movement of the helmet, skull, or skin, not necessarily the brain, which we all know moves independently of the skull. However, there is a lack of normative values, and is really more of a screening tool because you're not really assessing the movement of the brain itself, but getting some idea of the impact.

There are also mobile and tablet applications and the one that we hear about most frequently is called the ImPACT, Immediate Post Concussion Assessment and Cognitive Testing. It is FDA-approved for assessment of concussion across four cognitive functions: verbal memory, reaction time, visual-motor speed, and visual memory over 20 to 25 minutes using an installed or online program.  It does require baseline, post-injury assessment and trained healthcare professionals. So, this is not something that you pull up on your iPad and administer without any training. Also, it's not truly a sideline eval because athletes are removed from play.

There is an impact quick test that does not require removal from play, but it also doesn't require a baseline. So, it needs additional validation. There are other mobile applications, but the quality and reliability of those are being studied to determine their ability to provide important actionable information to clinicians and patients. We have to do more research on mobile apps. There are plenty of them, but we really need to show evidence for qualifying these instruments and preventing unvalidated or harmful instruments for market adoption.  Just because it can be purchased in the app store, doesn't mean that it's something that should be used on the sidelines, especially without the validation piece.

Finally, there are biomarkers. Through the TRACK-TBI Study, a lot of research is being conducted that provides objective values at threshold suspicious for CT-positive injury and can quickly triage an athlete not only for removal from play but to a medical center emergently. Blood-based biomarkers, in particular, are specific to brain injury and there is a lot of research still underway. If we get to a point where we can actually use blood-based biomarkers on the sideline it may be a very immediate way to ensure that somebody who has sustained a concussion does not return to play.  So, very rapid results could become available via clinical platforms.  If you want more information on those, check out the TRACK-TBI and ALERT-TBI studies.

Interview

Let’s say you have a patient or client with mild traumatic brain injury. It could be a post-sports injury, a post-blast injury, or falling off of a motor scooter. In the evaluation process, we want to start with an in-depth interview that is problem-focused. We want to focus on what the cause of the injury was, their current symptoms, and the length of symptoms.  We want to know the person’s education and employment status, and the impact of symptoms.

We want to do some motivational interviewing to help set the hook for treatment.  Interviewing also helps to determine what is impacting the patient the most and what they want to focus on. We want to dig into these questions, have good counseling skills with empathic listening, being sure to validate their symptoms.

Observational Evaluation

During observational evaluations, we are giving the patient a functional task and observing his or her performance. We will then increase the task complexity or decrease it as necessary. Remember, it's important to have the qualitative piece as well as a quantitative assessment.

Observing the patient allows us to see their appeared effort. It allows us to see their behavior during evaluation, and it plays a large role in the overall assessment. Standardized assessments give little insight into functional deficits. For example, a  patient has word-finding issues and they're having trouble coming up with the right word when they're at a work meeting. But you give them the Boston Naming Test and their scores are in the normal range.  That's a prime example of that quantitative evaluation not demonstrating their functional issues. So, we need observational evaluation which ties in well with a thorough patient interview. We see what they are reporting and then we can determine how to evaluate that functionally.

Functional assessment in any patient population, including mild traumatic brain injury, is extremely important as it gives us a snapshot of how the patient is getting by in their day-to-day life with their injury or diagnosis. Think about being back in high school and taking standardized assessments. You may have performed exceptionally well in the classroom, but you just weren't a good test taker. The same idea applies here but in the opposite way. The patient is a great test taker and can sustain their attention during portions of the assessment, but functionally they break down. Observational evaluations will tease out some of those mild issues that you're hearing about from the patient, but maybe the test doesn't show it.

I'll give you some examples of some observational functional tasks shortly. But, the idea is to increase complexity as you go through the assessment. If the patient's doing really well on a functional task, you're going to constantly increase the complexity so that you can see where they're having some breakdowns.

An example of this is asking the individual to use an internal memory strategy, like an acronym or a pneumonic association, to recall 5 locations we’ve provided. We can ask them to use external memory strategies, depending on their level of functioning, by having them write it down or put it in their phone to recall those five locations.

Another example is if you're in a clinic, maybe they go up to the front desk person, then a treatment room, and then the waiting room. They are asked to remember those five locations, however they can. This type of task shows us what they've been using for compensation prior to the assessment.   We can increase the complexity of this task by taking the patient into an unfamiliar environment and asking them to find the various locations.

When I worked at a large military hospital, I saw patients at a clinic outside of the hospital.  I would take the patient into the main hospital and ask them to look for five locations that I had given to them.  They know nothing about this hospital, I’m putting them into an unfamiliar location and I am asking them to 1) remember these five locations and 2) problem solve how to find the locations. So, we're really increasing that complexity. That allows us to observe their attention. Are they constantly distracted? We're looking at memory. Are their strategies working? If they said, “Yeah, yeah, I can remember it all. I’ve got this. I don't need to write it down. I don't need to put it in my phone.”  Is that working? Is their internal strategy working? Are they able to remember it?

We can observe their pragmatic skills during these types of scenarios. Are they looking people in the eye or are they solely focused on the task? Are there any signs and symptoms of anxiety? With mTBI, especially if they've had the symptoms over an extended period of time, the task might be tapping into some psychological symptoms such as anxiety. Service members and veterans may have a co-morbidity of mTBI and psychological health disorders, post-traumatic stress, anxiety, depression, etc. So, we may see some of these psychological components impacting a patient’s function during this type of task.

To reiterate, the observational evaluation is so important because it really helps peel away the layers of mTBI which is so complex. Calling the injury “mild” is kind of ironic because in some ways they are some of the most challenging patients that we can treat and evaluate.

Informal Screeners

Below are some informal screeners:

• Montreal Cognitive Assessment (MOCA)
• Cognistat
• Mini-Mental State Examination
• St. Louis University Mental Status (SLUMS)
• Others?

Through my experience and reading the research, these are the ones that are frequently used in hospitals.  I know a lot of hospitals also create their own screeners since they are not standardized. The examples that I have listed above are standardized but they are still screeners. So, some hospitals have informal questions that might look at the same areas such as memory, attention, problem-solving, and visual-spatial activities.

Formal Evaluation

I have broken down the formal evaluations by symptom areas or areas of deficits. The following are more standardized formal evaluations.

Executive Functioning

When we are evaluating executive functioning, the Behavioral Assessment of Dysexecutive Syndrome (BADS) and the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) can be administered. These tools assess the ability to plan, figure out a problem, execute a solution, and evaluate your performance at the end.  

Attention

The Test of Everyday Attention (TEA) is great for assessing attention.  I like this one because it's more functional. It includes tasks like looking at a map for various locations and various symbols. The patient is trying to attend to sound and also focus on reading those materials.  The Attention Process Training Test (APT) assesses similar skills and ties in well to the APT hierarchical treatment.

Memory

There are many assessment tools for memory, but I really like the Rivermead Behavioral Memory Test (RBMT-III) because it's functional. Patients or clients are given areas around the room to find things. We're asking them to do the typical remembering of names and dates etc, but it's more functional. Additionally, they're getting up and moving so if you aren't able to get out and do more of an observational evaluation, this tool is something that can provide that opportunity as well.

Word Finding/Language

I talked about the Boston Naming Test earlier.  There are some stickers that are available for the Boston Naming Test because some of the pictures were insensitive. So if you don't have those, definitely look into it if that's something you're interested in. Also for word finding and language, the subtests of the Woodcock-Johnson III Tests of Cognitive Abilities are good. That test covers everything! It’s really going to dig into those areas of naming and word finding.

Stuttering

If stuttering does present itself, you can give a formal Stuttering Severity Instrument (SSI) which is a great tool.

Considerations When Evaluating

As I mentioned before, formal evaluation may not be sensitive enough to pick up mild symptoms. Because we may not be seeing some of these mild symptoms on our formal evaluations, we want to use functional observation as a component of the evaluation. That will help us get a full picture of our patients.  Additionally, motivational interviewing involves validating patients. Listening to what they're reporting may assist with identifying a patient’s functional impairment.

Case Study #1

I want to share a case study and open it up for discussion.  This is a 30-year-old male status post motor vehicle accident.  The injury occurred three weeks ago. Symptoms include a consistent headache of four out of 10, short-term memory problems (e.g., memory for people's names, remembering the location of keys, leaving the oven on), “tip of the tongue” word-finding difficulties, and problems paying attention at work, where he is a CPA. 

Based on what we've discussed and based on your experience, where do you start with this patient? What's the first thing you do? How do you get them engaged?

(Participant suggestions):

• Address the headache since that can be a distraction
• Consult for pain medications - Pain, of course, needs to be addressed because that is a distraction and creates an attention issue.
• Ask him how often he's getting these headaches and the pain scale.
• Find out what the functional priorities are of the patient. What does he want to improve? What's bothering them the most? Does he want to return to work as a CPA? If so, what's breaking down at work? What are the issues there?
• Motivational interview as the first step - Engaging your patient in that first evaluation session starts that rapport, gets them engaged in treatment, helps them to realize that you are there for them.
• Plan your goals around their function and what they want.
• Ask what strategies he's already using to compensate.  Is he writing things down? Is he putting things in his phone? Is he sending himself calendar invites? If he is doing none of those maybe that's part of the reason why some of these things are breaking down.

The next question to think about is what other professionals should you involve? We talked about getting a medication consult from the primary care physician. But what other professionals do you want to be involved with somebody who's three weeks post-injury?

(Participant suggestion):

• Neurology
• Neuro-psych
• Counselor - Psychology in any form, whether that's social work, a counselor, psychiatry, psychology
• Family - Bringing in their family and their support system, especially the longer they get out from treatment is so important because we can't be there with them every day and that's not our job. The people who are probably seeing even more of a functional deficit are their family members and their coworkers. Getting in there and really understanding what the family is seeing and providing that family education is key.

I'll talk more about that in Part 2 on treatment. But family education is so important and also validating to the family. If their loved one is struggling to complete a task and the spouse feels like he or she is nagging all the time, teaching them how to deal with that helps if there's resentment that's starting to build because things aren't being completed. We need to be educating about the brain injury and educating about the brain. A participant is also suggesting to ask the patient for permission to talk to their manager at work to determine exactly what the job challenges are and how to incorporate that into therapy.  This is a great idea and the key is asking the patient for permission.  Understanding the work environment can sometimes be a great idea and sometimes it is not. It depends on how open and accepting employers are in terms of HR, etc.

So again, we want to have a good understanding of what their functional areas of weakness are and figure out how to build their treatment plan around that. The evaluation is just the tip of the iceberg to get you there.

What are some possible areas of treatment for this patient?  Where would you start with somebody like this? Again, it depends on those points that we just listed.  Let's say this gentleman really wants to return to work. He's struggling to find the right words when he's in meetings, and he can no longer track some of his patient accounts. Where would you start?

(Participant suggestions):

• Home environment safety – Is he leaving the oven and the stove on? Is he leaving his door unlocked, etc?
• Internal and external strategies for specific issues - If he’s forgetting patient accounts and losing track of emails or phone calls, how is he tracking those things? Does he have a compensatory strategy system that's consistent and in place that he’s using every single day?
• Attention strategies - Reducing distraction. Working from home for some of us is great and distractions may be more limited than in the office. For others, it could be a lot worse.
• Organization and time management
• Self-cuing
• Using materials from the patient's work during structured treatment

Again, these suggestions are all about function. You're not using worksheets. You are focused on evaluating the patient to determine what they need and then helping to structure the treatment to give them what they need and to let them figure out for themselves what they need. We want to empower them.

Case Study #2

The next case study that I want to share is a patient that I was talking to just recently.  This individual had a history of nine concussions during the course of football in high school with frequent loss of consciousness. He is now 12 years post-injury. He started having symptoms of hypersexuality. He described himself as being manipulative when it came to relationships. He is very emotionally unstable. He actually works with patients and couldn't remember his patients' names, or he'd be reading a chart and would forget what he'd already read to the patient. So, he was repeating himself. Attention and memory were huge issues. He also talked about losing his temper frequently. He would find himself driving and not remember where he was going.  He told me that he frequently set fires by accident because he was leaving the stove on.

Where do you start with this patient? Again, he is nine to 12 years out from the first of his concussions. His MRI did also show a lesion or an infarct. So, he has an MRI-proven brain injury in the frontal lobe.

(Participant suggestions):

• Psychology - Absolutely, especially after this amount of time and all of the behavioral issues likely resulting from the frontal lobe injury and executive dysfunction.
• Lab work - Yes, he actually mentioned that they were finding testosterone issues in him.
• Assistance in the home - He does have a wife and she is extremely supportive. But she is beginning to get frustrated especially with some of his emotional dysregulation and they do have a small child.
• Endocrinology 

So, we can see the complexity of this case. He's had multiple concussions which then becomes, not one mTBI but multiple mTBIs.  It can progress to more moderate to severe. You are looking at attention, memory, and word-finding. You're looking at the psych piece, the lab work, the endocrine dysfunction, neuroendocrine dysfunction, all of these pieces.

He also mentioned being desensitized to noise, which could trigger inattention and irritability. He mentioned vestibular issues as well. These are all areas to really consider.  As I mentioned before, for being called a “mild” injury, these patients are so complex.

I want to conclude by saying, “function, function, function”. Do that motivational interview and get them engaged. Figuring out a way to empower them to own their treatment and advocate for themselves. Validating what they're going through can help guide treatment.

Questions and Answers

In many areas of our field, we are often integrating some quality-of-life measures into our evaluations post-treatment not only because they are useful to us but also might help with insurance purposes if we can show quality-of-life improvements even if you're not able to see big jumps on a formal evaluation measure. Do you have any recommendations of measures that might be incorporated? Or how do you feel about that whole idea?

There is a quality-of-life measure, the Neuro-QoL, focused on brain injury that is now being used frequently to help justify treatment and insurance because it is standardized. I am 100% on board because you can continue to evaluate with those measures and then you can demonstrate progress. There is also the QOLIBR, Quality of Life After Brain Injury.

Could you redefine the motivational interview?

Absolutely. With motivational interviewing, the formal version of it, you're actually setting goals from it. You're saying, what are your symptoms? (I'm very much summarizing this. I'll get more into this too in the treatment course.)  What are your areas of weakness? If, for example, a person is having difficulty with word-finding, what percentage of the time would they say that is? That gives you a baseline percentage. Then you and the client work together to come up with where they want to be. That motivational interview helps to get that buy-in, set the goals, and then work from there. You're getting the full case history, of course, but you're really starting to set some of those goals from the motivational interview. If you go into McKay Sohlberg's work, there's a lot of great motivational interviewing research available that would help as well.

What was the issue with the MOCA in the news?

It was administered to President Trump during the last administration and released in the news. The actual assessment was posted on a lot of news organizations which then creates difficulty with validity when it's become common practice. But I know the MOCA now has specific training that providers need to take. I'm not sure if it's a formal certification. So, that's how it became kind of public.

What examples might you offer for your patients whose word-finding passes word-finding tests, but troubles them from day-to-day?

This is where we're going to get into the insurance issue. So, what if they're passing everything with flying colors? Let's say your patient passes the Boston Naming Test with no issues, which happens frequently. If I had the time, I would then give some of those Woodcock-Johnson Tests of Cognitive Abilities focused on word-finding because they are a little bit more nitpicky. But, I would also do more functional tasks. For example, this is also a treatment task, but if you're working with somebody who is in business development or government contracting or somebody who might be doing a lot of presentations, ask them to pick a presentation topic and present it to you and actually observe them.  That task can cause some stress, right? You're going to observe some of those functional issues. Usually, you're going to have some breakdown. You can have them start with presenting to you and then have them present to their family and record it. You can observe them in that situation. Having them present it to you can add a little bit of stress, or having them present it to their treatment team adds even more stress. It's that functional observational piece. You can see, ideally, some of that breakdown in word-finding. You could also get them out in the community where you can see how some of the distractions around them might contribute to a breakdown in some of their word finding.

My son has had two concussions, but we've never been recommended for any follow-up treatment other than checking in with the PCP. When does a client typically get referred for follow-up treatment from us as SLPs?

I think what a PCP is usually looking for is any continued symptoms.  If there are symptoms they may refer, but they may not because there's also the argument that children's brains are plastic. If it was my child and I was seeing continued symptoms, I would go ahead and advocate. So, if you're concerned, then ask for follow-up treatment.

Do you have any suggestions on strategies for adapting motivational interviewing techniques for people who seem to have reduced awareness of their deficits?

That is a situation where I will want to get family support and buy-in. That's definitely challenging because you're going to have to try to demonstrate that patient or client's deficits to them through family story, family report, at work, or even with you if they're comfortable with videotaping. However, even with that, you're not always going to get the awareness. It can be tricky. And sometimes in that situation, goal-setting may need to occur. That's usually not a mild TBI situation so you may need to engage psychology.

(Moderator) I used to work in a private practice that served a lot of individuals with mild TBI.  So often, their main complaint was, “Nobody else sees these problems, but I know that I am not functioning like I was.” They may be doing pretty well, but if they were high-functioning individuals before the mild TBI, it's so frustrating for them to not be able to function at that level anymore.  They're the ones who are typically acutely aware of the problem.

Were the MOCA and the SLUMS both originally established as a screen for Alzheimer's?

Yes, both of them were used for mild cognitive impairment for Alzheimer's or other dementia.  They're now used for many neuro populations. Sometimes that is part of the issue with knowing if we are truly evaluating the right population?

Is screening for a mild traumatic brain injury the same as screening for a concussion, or are there different screening tools?

A concussion is a mild traumatic brain injury. So, yes, they are the same. It is more about where they are happening. If you're looking at a sports concussion and an athletic trainer is on the sideline, they're going to be using a different tool than SLPs might use in a treatment room.

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Ed. 4. Washington, DC. American Psychiatric Association.

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