current tests for measuring cognitive-communication deficits (CCD) of TBI, the ..... (FAVRES; MacDonald, 2003), and the Attention Process Training Test ...
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Assessment of Cognitive-Communicative Disorders of Mild Traumatic Brain Injury Sustained in Combat Christine Parrish, Carole Roth, Brooke Roberts, Gail Davie Division of Speech Pathology, Department of Otolaryngology Naval Medical Center San Diego, CA The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Abstract Background: Mild traumatic brain injury (mTBI ) is recognized as the signature injury of the current conflicts in Iraq and Afghanistan, yet there remains limited understanding of the persisting cognitive deficits of mTBI sustained in combat. Speech-language pathologists (SLPs) have traditionally been responsible for evaluating and treating the cognitive-communication disorders following severe brain injuries. The evaluation instruments historically used are insensitive to the subtle deficits found in individuals with mTBI. Objectives: Based on the limited literature and clinical evidence describing traditional and current tests for measuring cognitive-communication deficits (CCD) of TBI, the strengths and weaknesses of the instruments are discussed relative to their use with mTBI. It is necessary to understand the nature and severity of CCD associated with mTBI for treatment planning and goal setting. Yet, the complexity of mTBI sustained in combat, which often co-occurs with PTSD and other psychological health and physiological issues, creates a clinical challenge for speech-language pathologists worldwide. The purpose of the paper is to explore methods for substantiating the nature and severity of CCD described by service members returning from combat. Methods: To better understand the nature of the functional cognitive-communication deficits described by service members returning from combat, a patient questionnaire and a test protocol were designed and administered to over 200 patients. Preliminary impressions are described addressing the nature of the deficits and the challenges faced in differentiating the etiologies of the CCD. Conclusions: Speech-language pathologists are challenged with evaluating, diagnosing, and treating the cognitive-communication deficits of mTBI resulting from combat-related injuries. Assessments that are sensitive to the functional deficits of mTBI are recommended. An interdisciplinary rehabilitation model is essential for differentially diagnosing the consequences of mTBI, PTSD, and other psychological and physical health concerns. Brain injury is well recognized as the signature injury of the Global War on Terror (GWOT), as most service members are surviving significant blast-induced injuries due to
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advances in body armor and head protection (Hoge et al., 2008; Okie, 2005). While there is a wealth of literature describing the cognitive-communication impairments caused by severe brain injuries resulting from falls, assaults, and motor vehicle accidents, many of the soldiers, sailors and Marines returning from the GWOT have been diagnosed with mild traumatic brain injuries (mTBI) following single or multiple blast exposures in combat. As wounded service members and veterans recover and return to their military and civilian communities, speechlanguage pathologists (SLPs) will be treating them for cognitive-communication problems. Therefore, it is imperative to understand the nature and severity of their problems in an effort to address their rehabilitative, social, educational, and vocational needs.
Cognitive-Communication Deficits Cognitive-communication disorders encompass difficulty with any aspect of communication that is affected by disruption of cognition (ASHA, 2005a, 2005b). The cognitivecommunication deficits (CCD) following mTBI sustained in combat are not well understood. What little is known suggests that the CCD in this population are multi-factorial in nature. Combat-acquired brain injury often occurs in the presence of highly stressful experiences that can result in debilitating psycho-pathological reactions, leading to persisting psychological symptoms such as post-traumatic stress disorder (PTSD), depression, anxiety, and adjustment disorders (Glaesser, Neuner, Lutgehetmann, Schmidt, & Elbert, 2004). In fact, PTSD has been associated with mTBI in as many as 71% of soldiers sustaining altered or loss of consciousness (Hoge et al., 2008). The combination of mTBI and psychological health issues complicates accurate assessment and diagnosis of cognitive-communication abilities, due to the overlapping symptoms of PTSD and mTBI (Danckwerts & Leathem, 2003; Roth, 2007). The purpose of this paper is to describe our experience evaluating the cognitive-communication abilities of combat-injured service members returning from Iraq and Afghanistan. Advancements in the identification of individuals with mTBI have evolved from the battlefield to military treatment facilities (MTFs) in the United States, such as Walter Reed Army Medical Center and Naval Medical Center San Diego, since the onset of the GWOT. Improved recognition of the signs of mTBI is the result of new screening measures and extensive education regarding brain injury provided at multiple levels including forward surgical teams in theater, combat support hospitals, and level IV military hospitals (e.g., Army Hospital, Landstuhl, Germany). Early detection of the symptoms of mTBI has been promoted at all levels of military medical care, resulting in more immediate evaluation and treatment of mTBI than ever before. Furthermore, the military has made a concerted effort to recognize the presence of persisting CCD related to previous deployments dating as far back as the beginning of the war, leading to a greater number of referrals for cognitive-communication assessments. The most common physical symptoms reported by service members returning from combat include headache, nausea, vomiting, fatigue, insomnia and other sleep disturbances, sensitivity to lights and noise, blurred vision, dizziness, and poor balance (Alexander, 1995; DVBIC, 2006). In addition, patients with mTBI complain of cognitive-communication problems including attentional impairments, reduced processing speed, memory dysfunction, impaired executive functioning, and language difficulties (Binder, 1997; French & Parkinson, 2008). Following mTBI, the physical and cognitive symptoms are transient, with most people recovering within weeks to months following their injury (Evans, 1992). Only 10-15% of mTBI patients have disabling symptoms that last years after injury (Kushner, 1998; Willer & Leddy, 2006). For these individuals, the cognitive sequelae can lead to persistent post-concussive syndrome (PCS), defined as the continuation of at least three of the following symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light (Legome & Wu, 2006). A brief period of dazed consciousness immediately after a concussive event can lead to significant limitations on one’s ability to function in competitive work and social contexts (Alexander, 1995). Statistics quoted
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in the literature on PCS are based primarily on mTBI resulting from sports-related injuries, falls, assaults, and motor vehicle accidents. The biomechanics of blast injury are known to differ and, therefore, the long-term impact on physical and cognitive-communication functioning remains unclear. SLPs have traditionally played a major role in the evaluation and management of cognitive-communication disorders following head injury (ASHA, 2007). Consistent with the 1998 NIH Consensus Statement on Rehabilitation of Persons with Traumatic Brain Injury, SLPs work to enhance the ability of individuals with TBI to function in all aspects of family and community life by utilizing restorative and compensatory treatment approaches to acute and post-acute rehabilitation with the patient and caregivers. However, there are no standardized assessment batteries or evaluation protocols for documenting the CCD following mTBI. SLPs are challenged with defining and administering consistent and comprehensive evaluations of service members returning from combat with blast-related TBI symptoms in an effort to understand the nature of the impairments and to provide the most effective interventions.
Assessment Measures According to preferred practice guidelines of the American Speech-Language-Hearing Association (ASHA, 2004) the purpose of the assessment of cognitive-communication skills is to identify and describe underlying strengths and weaknesses related to cognitive, executive function/self-regulatory, and linguistic factors, including social skills, as well as the effects of cognitive-communication impairments on the individual's capacity and performance in everyday communication contexts or his or her participation. Outcomes of the assessment may include diagnosis of a cognitive-communication disorder, clinical description of the characteristics of a cognitive-communication disorder, prognosis, recommendations for intervention and support, and referral for other assessments or services. Historically, SLPs utilized a variety of measures for assessing patients with mTBI. In a survey study of SLPs who were assessing mTBI, Duff, Procter, and Haley (2002) noted that the most frequently employed assessment instruments were the Ross Information Processing Assessment (RIPA; Ross-Swain, 1996), the Boston Diagnostic Aphasia Exam (BDAE; Goodglass, Kaplan, & Barresi, 2000), the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 2000), and the Scales of Traumatic Brain Injury (SCATBI; Adamovich & Henderson, 1992). The authors concluded that two of the most popular instruments used for assessing cognitive-communication function were designed to assess aphasia, not traumatic brain injury. Furthermore, the authors state, “These instruments do not assess the cognitive deficits that are the hallmark of TBI, and they are particularly insensitive to subtle deficits found in individuals with mTBI” (p. 782). There have been other criticisms of existing test batteries, including the absence of a comprehensive assessment that examines all major areas of cognitive-communicative functioning and the lack of a validated assessment tool within a naturalistic environment. To address some of the issues described above, the Academy of Neurologic Communication Disorders and Sciences (ANCDS) embarked on a 5-year project to develop a range of evidence-based practice guidelines for populations of patients with specific neurological impairment, including cognitive-communication disorders after traumatic brain injury (Frattali et al., 2003). In attempting to address the question of what tests can or should be used for assessment of communication ability in persons with TBI, the committee completed a review of 127 standardized assessments that were recommended by SLPs, test publishers, or distributers for use with TBI patients (Turkstra et al., 2005). Further review was conducted of only those tests that were explicitly designed for or administered to patients with TBI. Thirtyone tests for children, adolescents, and adults met this criterion and were then reviewed for reliability and validity measures established by the Agency for Health Care Policy Research (AHCPR). Seven tests met these strict criteria (see Appendix).
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In the summary of their review, Turkstra, Coelho, and Ylvisaker (2005) stated, “The tests recommended by speech-language pathologists were strong in content validity but relatively weak in construct validity” (p. 219). The authors went on to criticize the “striking absence of a test developed for the evaluation of communication in individuals with cognitivecommunication disorders, versus tests of basic neuropsychological functions that may be administered by speech-language pathologists or tests borrowed from other populations, such as aphasia” (p. 219). Whelan, Murdoch, and Bellamy (2007) reported a case study that documented impairment in cognitive-communication skills following mild TBI utilizing a test protocol that assessed higher order linguistic functioning. Their protocol consisted of the Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI; Adamovich & Henderson, 1992), the Neurosensory Centre Comprehensive Examination of Aphasia (NCCEA; Spreen & Benton, 1969), the Boston Naming Test (BNT) (Kaplan et al., 2000), the Test of Language Competence-E (TLC-E; Wiig & Secord, 1989), the Word Test (Revised; Huisingh, Barrett, Zachman, Blagden, & Orman, 1990), the Wiig-Semel Test of Linguistic Concepts (Wiig & Semel, 1974), and an on-line lexical decision task incorporating real and non-real words (Azuma & Van Orden, 1997). The authors emphasized the importance of assessing higher-level linguistic skills requiring input from the frontal lobes, skills that have been associated with severe TBI. They selected these instruments because they had documented validity and reliability as measures of language functions. Specific deficits in attention, word retrieval, and executive functions were identified by the instruments they administered. Many authors recommend a combination of standardized and non-standardized assessments to document real world functioning (Turkstra et al., 2005; Coelho et al., 2005; Milton, 1988; Sohlberg & Mateer, 1989). The inclusion of non-standardized and “informal” assessments is critical in the TBI assessment process, as the testing conditions themselves may “compensate for the cognitive communication problems traumatically head-injured patients have in society” (Milton, 1988, p. 5). According to Turkstra and McCarty (2006), communication competence, that is, the use of language within social contexts, is best assessed outside of the clinic in conversational interactions rather than in structured clinical interviews.
NMCSD Protocol At the Naval Medical Center San Diego (NMCSD), patients sustaining a combat injury are automatically assigned to the care of the comprehensive and complex combat casualty care (C-5) team. The C-5 multidisciplinary team consists of physicians, nurses, therapists, case managers, military, and civilian personnel involved in supporting the medical and military transition needs of combat-related wounded and ill service members. The Speech-Language Pathology Division may receive referrals for cognitive-communication evaluations from any member of the C5 team. The majority of the consultations are requested by otolaryngology, primary care, case management, neurology, and neuropsychology. Between September 2006 and October 2008, more than 200 combat-injured service members were referred for speech pathology evaluations. The typical combat-injured patient seen in the clinic was an enlisted male serving in the infantry, between the ages of 22 and 25, with a high school diploma or equivalent and a history of blast exposure resulting in a brief period of altered or loss of consciousness as reported by the individual. Detailed documentation of the combat injury, including duration of loss or altered consciousness and period of posttraumatic amnesia, was scant for the majority of the patients. Most patients completed neuropsychological testing prior to being referred to speech-language pathology. Many patients had multiple co-morbidities including PTSD or other psychological health concerns, such as depression, anxiety, or adjustment disorder.
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To begin addressing the challenge of objectively capturing the presence of cognitivecommunication deficits following blast exposures, the NMCSD SLP staff completed a comprehensive review of the literature on assessment of cognitive-communication disorders. A protocol was developed with the goal of answering two questions: 1. What are the functional symptoms of CCD being described by service members? 2. Which evaluation measures are best for identifying CCD of mTBI sustained in combat? The protocol consisted of a subjective rating scale, selected portions of various standardized test batteries, and informal measures. Completing the individual evaluations required at least two 1-hour visits and sometimes three. The protocol was modified over time to include informal measures of conversational skills collected during a cognitive-communication group. A retrospective study of the evaluations of the service members referred during this time period found 117 completed evaluations for patients exposed to blasts. Cases excluded from this study included those who sustained brain injury from motor vehicle accidents or those found to have incomplete data. Some patients failed to return to the clinic to complete testing. To better understand the nature of the cognitive-communication concerns of service members returning from combat, the Speech Language Cognitive Rating Scale (SLCRS) was developed and given to patients to complete. This rating scale was adapted from a questionnaire developed by Sohlberg and Mateer (2001) for use with the Attention Process Training (APT) program. The NMCSD questionnaire included 14 questions that service members rated on a 1 to 4 scale ranging from “not a problem” to “always a problem.” Selected subtests from the following evaluation instruments were used to evaluate cognitive-communication abilities: Woodcock-Johnson III (WJ-III; Woodcock, McGrew, & Mather, 2001), the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; MacDonald, 2003), and the Attention Process Training Test (Sohlberg & Mateer, 2001). The WJ-III consists of two distinct, co-normed batteries: the WJ-III Tests of Cognitive Abilities (WJ-III COG) and the WJ-III Tests of Achievement (WJ-III ACH). Finally, informal measures of conversation were collected in a group context. The WJ-III was selected because it provides individual subtest and cluster standard scores and percentiles and is normed on over 8,000 subjects, ages 2 years to geriatrics; thus, it provides a strong normative reference against which to compare the patient population. In addition the test is comprehensive in nature, examining both cognitive and linguistic skills across a variety of tasks. Although it has not been normed on patients with brain injury, it has been used extensively to evaluate the cognitive-communication abilities, scholastic aptitude, oral language, and achievement across the age-span to predict academic and vocational success. The test has been shown to be sensitive for identifying learning disabilities. The FAVRES was included because it was designed to evaluate subtle cognitivecommunication difficulties “which may not be apparent on typical standardized tasks” (MacDonald, 2005, p. 1). Unfortunately, this instrument was not included in the test protocol until early 2008, when it became available to the NMCSD SLP staff. The Attention Process Test (APT) was included in the protocol as a baseline measure of attentional processes frequently impaired following mTBI. Rehabilitation of attentional deficits using the APT program is one of the few evidence-based treatments for persons with mTBI (Rohling, Faust, Beverly, & Demakis, 2009). The APT test provides an assessment of the five theoretical domains of attention (focused, sustained, selective, divided, and alternating) under different conditions. The test’s authors do not advocate for using the APT test as an isolated assessment measure, but rather as a baseline for defining where to begin treating attention using the APT program. It provides the scope of attention performance of mTBI individuals in a small sample.
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Informal evaluation of social language skills was completed during weekly cognitivecommunication groups. Pragmatic skills such as topic maintenance, coherence, topic initiation, turn-taking, and paralinguistic functions were tracked and described on-line for later review and interpretation.
Assessment Findings Evaluation results reported here represent only preliminary impressions, because the sample size is small (N=117). The test protocol continues to be used in the clinic, and final data analysis will not be completed until the sample size is much larger. On the SLCRS self assessment, patients rated irritability as the foremost concern, followed by difficulty with word finding and recalling names. Performance results from the WJ-III revealed that, while the majority of the service members scored within normal limits on the clusters and subtests focused on language knowledge, measures of cognitive efficiency were consistently below the mean when compared to normals. The group mean across the WJ-III subtests fell within normal limits with a standard score of 92, but was less than the normative mean of 100. More than 25% of patients scored below one standard deviation on 8 of 11 subtests and clusters. Fifty percent of the patients scored below one standard deviation on measures of cognitive efficiency, visual matching, and retrieval fluency. Few patients had difficulties on subtests of auditory working memory and verbal tasks. Preliminary impressions of APT performance measures suggest that patients have greater difficulties on the selective and divided attention subtests when compared to normals. On the FAVRES, patients demonstrated accurate task performance and verbal reasoning skills; however, their performance reflected slow speed of information processing. Anecdotal review of pragmatic data suggests slow response time and difficulties with expansion, elaboration, and topic maintenance. Disturbed speech prosody—with repetitions, substitutions of initial words, and grammatical rephrasing of statements—was evident in some subjects, particularly in a group setting.
Discussion It was interesting to learn that patients rated irritability as their major concern; yet, they verbally complained most often of memory difficulties. Their awareness of their decreased emotional stability may reflect the challenges they face in re-integrating into their families and community; learning to cope with PTSD and depression; or their frustration with changes in their cognitive-communication abilities. As a group, the patients scored within the normal range on the WJ-III, with an overall mean only slightly below the test mean for the normative population. On the cognitive subtests, the patients scored below the mean by greater than one standard deviation with lower performances on tests of cognitive efficiency, visual matching, and retrieval fluency. Additionally, test data showed low performance scores on measures of attention and information processing, as well as difficulties with pragmatic communication and speech production. The speech pattern was characteristic of a motor speech or fluency disorder, but was inconsistent with the typical presentation of apraxia, dysarthria, or stuttering. The patients’ dysprosodic repetitions, substitutions, and rephrasing appeared to represent selfcorrections taking place following their verbal output. The corrections may reflect the use of compensatory strategies for extending processing time and rehearsing auditorily their verbal productions. Collectively, these findings provide evidence that the evaluation protocol was sensitive at measuring mild cognitive-communication impairments in the patient group. The goal of the SLP's evaluation is to document the presence and severity of CCD in service members returning from combat. It is not to diagnose mTBI; this is the role of the neuropsychologist, neurologist, and physiatrist. However, clinicians need to be cognizant that,
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following deployment, service members may present with a host of risk factors for CCD. It is well documented that cognitive impairments may co-exist with PTSD, depression, sleep disorders, pain, and medication effects (Danckwerts & Leathem, 2003; Gallassi, Di Sarro, Morreale, & Amore, 2006; Weiner, Freedheim, Schinka, & Velicer, 2003; Trudel, 2007; Terrio et al., 2009). The extent to which these co-morbidities contribute to test performance remains uncertain. Answering this question requires a coordinated and comprehensive interdisciplinary approach to the evaluation of CCD in mTBI. Speech Pathology, along with Neuropsychology, Neurology, Psychiatry, and other mental health disciplines, is an essential team member in the evaluation process.
Future Directions We continue to evaluate methods for improving our current test battery. For example, we want to implement a standardized pragmatic protocol and assess functional performance in natural communication contexts. Examples of instruments that may be considered for addressing these domains include the Profile of Pragmatic Impairment in Communication (PPIC; Linscott, Knight, & Godfrey, 2003), the Social Communication Skills QuestionnaireAdapted (SCSQ-A; McGann, Werven, & Douglas, 1997), the Profile of Functional Impairment in Communication (PFIC; Linscott, Knight, & Godfrey, 1996), and the Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A; Roth, Isquith, & Gioia, 2005). Once we have established a full complement of standardized and functional evaluation instruments, we plan to conduct further analysis to examine for the effects of co-morbidities on test performance. The impact of co-morbidities can potentially drive decisions regarding when to evaluate patients, which measures to use, and how to interpret the findings relative to treatment planning.
Summary The Global War on Terror has led to a significant increase in the diagnosis of mTBI in a large percentage of returning soldiers (Hoge, 2008). As a result, medical professionals, including SLPs all over the country, are being called upon to evaluate and treat CCD sustained in combat. Little is known about the CCD in this population, and accurate assessment is complex, requiring consideration of physical and psychological factors. Speech-language pathologists play a key role in early assessment, education, counseling, and direct intervention of persisting cognitive-communication impairments (ASHA, 2005b; Roth, 2008). An interdisciplinary rehabilitation model is essential to providing effective evaluation. There is a need for clinical research to expand our understanding of the impact of blast injuries on cognitive-communication processes, to define prognosis for recovery, and to design evidencebased intervention programs (Roth, 2008). Christine Parrish is a staff speech-language pathologist at Naval Medical Center San Diego. She has worked in the rehabilitation field for 15 years, specializing in evaluation and treatment of cognitive-communication disorders following traumatic brain injury (TBI). Ms. Parrish has worked with TBI patients at all acuity levels, including inpatient and outpatient rehabilitation and day treatment. She has participated in the evaluation and treatment of active duty service members since the onset of the Global War on Terror (GWOT) and is involved in ongoing research with this population. Carole R. Roth is chief of Speech Pathology at the Navy Medical Center San Diego and assistant professor in the Department of Speech-Language and Hearing Sciences at San Diego State University. Dr. Roth has many years of clinical experience working with acquired brain injuries. She was former president of the Boulder Chapter of the Colorado Head Injury Association and established a camp in the Rocky Mountains for survivors of traumatic brain
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injury. Dr. Roth has authored journal articles and has spoken nationally and internationally in the areas of motor speech disorders and rehabilitation following TBI. Brooke Roberts is a staff speech-language pathologist at Naval Medical Center San Diego (NMCSD). She earned her master’s degree in Communication Disorders from the University of Virginia. She has been a member of the Comprehensive Combat and Complex Casualty Care (C-5) program, the NMCSD multidisciplinary rehabilitation team, since November 2007. Her prior brain injury experience includes serving veterans in the VA system in Florida. Gail Davie is formerly a staff speech-language pathologist at Naval Medical Center. She earned her undergraduate and graduate degrees from Ohio University. She was a member of the Comprehensive Combat and Complex Casualty Care (C-5) program, the NMCSD multidisciplinary rehabilitation team. Her prior experience was working with adults with neurogenic communication problems at MD Anderson Cancer Center.
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Frattali, C., Bayles, K., Beeson, P., Kennedy, M., Wambaugh, J., & Yorkston, K. (2003). Development of evidence-based practice guidelines: Committee update. Journal of Medical Speech-Language Pathology, 11(3), ix-xviii. French, L., & Parkinson, G. (2008). Assessing and treating veterans with traumatic brain injury. Journal of Clinical Psychology, 64(8), 1-10. Gallassi, R., Di Sarro, R., Morreale, A., & Amore, M. (2006). Memory impairment in patients with lateonset major depression: The effect of antidepressant therapy. Journal of Affective Disorders, 91(2-3), 243250. Glaesser, J., Neuner, F., Lutgehetmann, R., Schmidt, R., & Elbert, T. (2004). Post-traumatic stress disorder in patients with traumatic brain injury. BMC Psychiatry, 4, 5. Goodglass, H., Kaplan, E., & Barresi, B., (2000). Boston Diagnostic Aphasia Examination (3rd ed.). San Antonio, TX: The Psychological Corporation. Hoge, C., McGurk, D., Thomas J., Cox, A., Engle, C., & Castro, C. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358(5), 453-463. Huisingh, R., Barrett, M., Zachman, L., Blagden, C., & Orman, J. (1990). The Word Test Revised: A test of Expressive Vocabulary and Semantics. East Moline, Ill: Linguisystems. Kaplan, E., Goodglass, H., & Weintraub, S. (2000). The Boston Naming Test (2nd ed). San Antonio, TX: The Psychological Corporation. Kushner, D. (1998). Mild traumatic brain injury. Archives of Internal Medicine, 158, 1617-1624. Legome, E., & Wu, T. (2006). Postconcussive syndrome. Retrieved December 24, 2008, from www.emedicine.medscape.com Linscott, R., Knight, R., & Godfrey, H. (1996). Profile of functional impairment in communication (PFIC). Brain Injury, 10, 397-412. Linscott, R., Knight, R., & Godfrey, H. (2003). Profile of pragmatic impairment in communication (PPIC). Unpublished manuscript, University of Otago, Dunedin, New Zealand. MacDonald, S. (2003). Functional Assessment of Verbal Reasoning and Executive Strategies. Ontario, Canada: CCD Publishing. McGann, W., Werven, G., & Douglas, M. (1997). Social competence and had injury: A practical approach. Brain Injury, 11, 621-628. Milton, S. (1988). Management of subtle cognitive-communication deficits. Journal of Head Trauma Rehabilitation, 3(2), 1-11. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury. (1999). Rehabilitation of persons with traumatic brain injury. Journal of the American Medical Association, 282, 974-983. Okie, S. (2005). Traumatic brain injury in the war zone. The New England Journal of Medicine, 352(20), 2043-2047. Rohling, M., Faust, M., Beverly, B., & Demakis, G. (2009). Effectiveness of cognitive rehabilitation following acquired brain injury: A meta-analytic re-examination of Cicerone et al.’s (2000, 2005) systematic reviews. Neuropsychology, 23(1), 20-39. Ross-Swain, D. (1996). Ross Information Processing Assessment. Austin, TX: PRO-ED. Roth, C. (2007). Mechanisms and sequelae of blast injuries. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 17(3), 20-24. Roth, C. (2008). Blast injury and mild TBI: Challenges for rehabilitation. CSHA Magazine. 38(1), 6-9.
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Roth, R., Isquith, P., & Gioia, G. (2005). Behavior Rating Inventory of Executive Function–Adult version (BRIEF-A). Lutz, FL: Psychological Assessment Resources, Inc. Sohlberg, M., & Mateer, C. (1989). The assessment of cognitive-communicative functions in head injury. Topics in Language Disorders, 9(2), 15-33. Sohlberg, M., & Mateer, C. (2001). Attention Process Training Test (APT-Test, 2nd ed.). Wake Forest: Lash & Associates Publishing/Training. Spreen, O., & Benton, A. (1969). Neurosensory Centre Comprehensive Examination for Aphasia. Victoria, British Columbia, Canada: University of Victoria. Terrio, H., Brenner, L., Ivins, B., Helmick, K., Schwab, K., Scally, K., Bretthauer, R., & Warden, D. (2009). Traumatic brain injury screening: Preliminary findings in a U.S. Army Brigade Combat Team. Journal of Head Trauma Rehabilitation, 24, 14-23. Trudel, T., Davanzo, J., Mattingly, E., Nidiffer, F., & Barth, J. (2007). Reintegrating military personnel after traumatic brain injury (TBI): A community integrated rehabilitation model in practice. Brain Injury Professional, 4(1), 22-25. Turkstra, L., & McCarty, J. (Nov. 1, 2006). Evidence based practice in traumatic brain injury: Assessment and intervention for cognitive communication disorders. Telephone Seminar sponsored by ASHA. Turkstra, L., Ylvisaker, M., Coelho, C., Kennedy, M., Sohlberg, M., & Avery, J. (2005). Practice guidelines for standardized assessment for persons with traumatic brain injury. Journal of Medical Speech-Language Pathology, 13(2). Turkstra, L., Coelho, C., & Ylvisaker, M. (2005). The use of standardized tests for individuals with cognitive-communication disorders. Seminars in Speech and Language, 26(4), 215-222. Weiner, I., Freedheim, D., Schinka, J., & Velicer, W. (2003). Insomnia. In Handbook of psychology (p. 320). Hoboken: John Wiley and Sons. Whelan, B., Murdoch, B., & Bellamy, N. (2007). Delineating communication impairments associated with mild traumatic brain injury: A case report. Journal of Head Trauma Rehabilitation, 22(3), 192-197. Wiig, E. H., & Secord, E. (1989). Test of Language Competence-Expanded edition. New York: Psychological Corporation. Wiig, E. H., & Semel, E. (1974). Development of comprehension of logical grammatical sentences by grade school children. Perceptual Motor Skills, 38, 171-176. Willer, B., & Leddy, J. (2006). Management of concussion and post concussion syndrome. Current Treatment Options in Neurology, 8, 415-426. Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). Woodcock-Johnson III. Itasca, IL: Riverside Publishing.
Appendix. Reliable and Valid Tests for TBI (Turkstra, Coelho, & Ylvisaker, 2005) •
American Speech-Language-Hearing Association Functional Assessment of Communication Skills in Adults (ASHA FACS)
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Behavior Rating Inventory of Executive Function (BRIEF)
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Communication Activities of Daily Living (CADL-2)
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Functional Independence Measure (FIM; Uniform Data System for Medical Rehabilitation)
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Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
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•
Test of Language Competence-Extended (TLE-C)
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Western Aphasia Battery (WAB)
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