Journalof Speech and Hearing Research, Volume 39, S5-S 17, October 1996
Treatment Efficacy: CognitiveCommunicative Disorders Resulting From Traumatic Brain Injury in Adults Carl A. Coelho Southern Connecticut State University New Haven Frank DeRuyter Duke University Medical Center Durham, NC Margo Stein* Health Care Consultant St. Louis, MO
Traumatic brain injuries (TBI) may result in a broad array of cognitive-communicative impairments. Cognitive-communicative impairments are the result of deficits inlinguistic and nonlinguistic cognitive functions. The speech-language pathologist functions as a member of the multidisciplinary team of professionals that collaboratively assess and treat individuals with TBI. The role of the speech-language pathologist includes assessment of all aspects of communication, as well as the communicative implications of cognitive deficits, and swallowing; treatment planning and programming, as determined by the individual's stage of recovery; client and family training/counseling; and interdisciplinary consultation. The effectiveness of speech and language intervention for specific cognitive deficits (e.g., attention, memory, executive functions) as well as general issues of social-skills training and early intervention are illustrated by scientific and clinical evidence from group-treatment and single-subject studies as well as case studies. KEY WORDS: traumatic brain injury, cognitive rehabilitation, communication disorders, intervention studies, treatment outcome
There is both scientific and clinical evidence that individuals with cognitivecommunicative disorders resulting from traumatic brain injury (TBI) benefit from the services of speech-language pathologists. This evidence is documented in experimental research, program evaluation data, and case studies. The purpose of this paper is to summarize the evidence pertaining to treatment efficacy for cognitive-communicative disorders secondary to TBI in adults. Olswang (1990) has pointed out that treatment efficacy is a broad term that can address several questions related to treatment effectiveness (i.e., Does treatment work?), treatment efficiency (i.e., Does one treatment work better than another?), and treatment effects (i.e., In what ways does treatment alter behavior?). Treatment efficacy studies have used either group or single-subject experimental designs to answer these
questions; both methodologies are included in this analysis. Other sources of information, including program evaluation data and case studies, lend support to experimental findings of treatment efficacy. Thus, such information is included in this review. Although program evaluation data cannot answer questions about causal relationships between the process and outcome of treatment, they can document trends intreatment for large patient/client populations, often defined by functional outcomes. Finally, case studies offer more individualized and patient/client-oriented accounts of treatment benefit.
Definition of CognitiveCommunicative Disorders Communication is a process by which information is exchanged (Davis, 1983). The ability to communicate requires a
*Currently affiliated with the American Speech-Language-Hearing Association © 1996, American Speech-Language-Hearing Association
Journalof Speech and Hearing Research
complex interaction between cognition and language (Adamovich, 1991). Cognitive skills include such processes as attention, memory, reasoning, problem solving, and executive functioning (i.e., self-awareness and goal setting, planning, self-directing/initiating, self-inhibiting, self-monitoring, self-evaluation, flexible thinking). Language skills involve transmission of spoken, written, or nonverbal messages (e.g., gestures, facial expression) and reception of auditory, printed, or nonverbal messages. Difficulty or failure with any of these expressivereceptive abilities or with any aspect of cognition may result in a breakdown in communication and thus the inefficient exchange of information. Traumatic brain injury may result in cognitive-communicative impairments. Cognitive-communicative impairments are those impairments of communication related to impairments of linguistic (e.g., syntax, semantics, metalinguistic skills) as well as nonlinguistic cognitive functions (e.g., attention, perception, and memory; ASHA, 1987,1990).
Incidence and Prevalence Data Traumatic brain injuries result from some form of trauma to the head. Such injuries are classified as either penetrating (e.g., a gunshot wound) or closed head injuries (e.g., resulting from sudden acceleration/deceleration forces, such as when a head strikes the dashboard of a car) depending on whether or not the meninges (the protective membranes that cover both the brain and the spinal cord) remain intact. A broader definition of closed head injury also includes injuries in which the meninges remain intact but are disrupted-as seen, for example, incases of shaken impact syndrome (i.e., child abuse in which a child is shaken violently; Levin, Goldstein, Williams, & Eisenberg, 1991). There are distinct differences between penetrating and closed head injuries in terms of type of deficits and recovery, the discussion of which is beyond the scope of this article (see Grafman & Salazar, 1987, for a review). Penetrating head injuries usually result in focal lesions to specific areas of the brain. Closed head injury may result in focal lesions, diffuse axonal injury (stretching, tearing, and shearing of nerve fibers), or a combination of both.
Although each type of injury may occur in any region of the brain and result in very different patterns of deficits, certain regions of the brain are highly vulnerable in closed head injury. For example, the prefrontal region (front of the brain just behind the forehead) and the limbic system (located deep within the center of the brain), as well as the connections between the limbic system and the prefrontal region, are most vulnerable (Levin & Kraus, 1994). Kraus (1993) estimated that 500,000 individuals sustain head injury each year (200 per 100,000 population). Of this number, 200,000 die, 50,000 to 100,000 survive with significant impairments preventing independent living, and more than 200,000 suffer continuing sequelae that interfere with daily living skills (Gualtieri, 1988; Jennett, Snoek, Bond, & Brooks, 1981; Kalsbeek, McLauren, Harris, & Miller, 1981; Kraus, 1978). Of the individuals who sustain TBI, nearly twice as many males as females are injured. The risk of TBI is higher among males 15 to 24 years of age and the elderly (over 75 years). Inthe United States, trauma is the third leading cause of death among individuals under the age of 35 (National Head Injury Foundation, 1983). More than two thirds of all head injuries are classified as mild. Definitions of mild TBI vary; consequently, it has been difficult to compare outcomes for such individuals from different treatment centers. The American Congress of Rehabilitation Medicine (1993) has defined mild TBI as traumatically induced physiological disruption of brain function manifested by at least one of the following: (a) any period of loss of consciousness; (b) any loss of memory for events immediately before or after the injury; (c) any alteration in mental state at time of injury (dazed, confused, disoriented); or (d) focal neurological deficits (may or may not be transient) that result in loss of consciousness for 30 minutes or less, an initial Glascow Coma Scale score of 1315, and posttraumatic amnesia not greater than 24 hours.
Effects of CognitiveCommunicative Disorders on Daily Life Activities The effects of TBI on the survivor and family are dependent, in large measure, on the nature and severity of the injury.
Because no two TBI cases are the same, each injury yields a diverse constellation of cognitive-communicative, physical, and psychosocial deficits. The degree to which these deficits impede the performance of everyday activities depends in part on the nature of the activities in which a particular individual was engaged before the injury. The impact of TBI is perhaps best understood when considered within the context of the World Health Organization's proposed classifications of impairment, disability, and handicap (World Health Organization, 1987). Impairment is defined as an abnormality in physical or mental function-for example, cognitive disruption such as decreased attention, which typically results from TBI. Disability refers to a limitation in performance of an activity because of an impairment; for example, difficulty sustaining attention would influence the ability to read and follow instructions. Handicap is a loss of social role function because of disability. Perhaps the most disabling and handicapping effect of TBI is a reduced capacity to pursue preinjury interests and daily activities at the same functional level. Such disability exists along a broad continuum that can range from requiring additional time to complete tasks to near total dependence on others for all basic needs. Symptoms following mild TBI are quite variable and may include difficulty concentrating under distracting conditions or problems managing tasks involving multiple demands. Areas commonly disrupted are attention, memory, and executive functioning. Mild TBI may also result in word-finding difficulties, decreased motivation, anxiety, depression, and irritability (Levin, Eisenberg, & Benton, 1989; Sohlberg & Mateer, 1989a). These deficits are present in spite of normal findings on conventional diagnostic procedures such as computerized tomography and magnetic resonance imaging. Longterm follow-up of patients with mild head injury often reveals loss of jobs, divorce, substance abuse, and generally disorganized lives. Alexander, Benson, and Stuss (1989) note that in individuals with prefrontal injury, linguistic skills are typically intact; however, they may show the following deficits: (a)disorganized or impoverished discourse (receptively and expressively); (b) awkward or inappropriate social interaction (i.e., difficulty with pragmatic
Coelho et al.: Treatment Efficacy in Cognitive-Communicative Disorders
dimensions of language, including difficulty interpreting social cues); (c) difficulty with abstract forms of language (e.g., abstract concepts, figures of speech, irony, sarcasm); (d) difficulty with flexibility in linguistic processing (e.g., ambiguity); or (e)difficulty with speed of processing. Injuries to the limbic system as well as the connections between the prefontal and the limbic structures are also characterized by generally intact linguistic skills, but are associated with inefficient learning of new information (including linguistic information) and reduced control over emotional responses. Jacobs (1988) surveyed the families of 142 survivors of severe TBI regarding whether or not the survivor was independent in a variety of behavioral skills. The skill areas involved a range of abilities (e.g., reading, writing, telling time, concentration, remembering, and orientation) and a range of complexity (e.g., for reading: reads and recognizes directional signs or reads books). Results indicated that TBI had a significant impact on the survivors' ability to independently perform a variety of daily living skills. The impact of TBI on the family may be equally devastating. Jacobs (1988) noted that although many survivors of severe TBI live with their families, they do not work or attend school and are dependent upon others for accomplishing daily skills, both inside and outside the home.
Role of the Speech-Language Pathologist The speech-language pathologist is a member of the team of rehabilitation professionals that collaboratively assesses and treats individuals who have sustained TBI (see Ylvisaker, 1994). Speech-language pathologists assume primary responsibility for the assessment of all aspects of communication: hearing screening (with referral for comprehensive audiologic assessment as needed), spoken language (comprehension & production), written language (reading & writing), cognitive-communicative functioning (i.e., exploring the communicative implications of impairments in such areas as orientation, attention, memory, reasoning, problem solving, executive functions), speech production (articulation, fluency, phonation, and resonance), augmentative and alter-
the best techniques for interacting with native communication, as well as swallowing. Upon completion of this assessthe patient/client. In later stages of rement the findings are interpreted, and a covery, traditional cognitive rehabilitation prognosis and treatment recommendatakes place. Individual and/or group treatment may be supplemented by comtions are formulated. Treatment planning includes collaboration with educational puter-assisted treatment. To facilitate and vocational specialists to enable the carryover of treatment objectives to TBI individual to succeed educationally nonclinical environments, contextuand/or vocationally. alization of treatment activities takes Speech-language pathologists are place as soon as it is feasible. For exresponsible for the establishment of treatample, early return to work with a job ment programs aimed at decreasing the coach or educational intervention with an effects of impairments in all aspects of emphasis on inclusionary placement and speech, language, cognitive-communisupport in that setting are methods to facative functioning, and swallowing. The cilitate carry-over. Family or significant treatment plan includes long- and shortother training/counseling, as well as interm objectives (reviewed on a regular terdisciplinary consultation and dismissal/ basis); information regarding frequency, discharge planning, also are ongoing. estimated duration, and type of service; and follow-up or referral to other profesDefinition of Cognitive sionals as necessary. In addition, Rehabilitation speech-language pathologists help to identify effective and functional supports Cognitive rehabilitation refers to a to enable cognitively disabled individutreatment regimen aimed at increasing als to be as independent and successful functional abilities in everyday life by as possible. Such supports may include improving an individual's capacity to procognitive prosthetic devices (e.g., cess and interpret incoming information. memory logs), adjustment of work expecTwo approaches to cognitive rehabilitatations (by co-workers and employer), tion-restorative and compensatorychanges in the work/classroom environhave been described. The restorative ment (e.g., allowing the individual to work approach is based on the notion that where distractions are minimal), modifineuronal growth, and thus improvement cation of teaching procedures to be conin function, is associated with repetitive sistent with the individual's cognitive exercise of neuronal circuits. Incontrast, strengths and weaknesses (e.g., elimithe compensatory approach operates on nation of time constraints, as in untimed the assumption that certain functions tests). Throughout the treatment planning cannot be recovered; therefore, the deprocess the issue of context must be velopment of strategies to circumvent carefully considered. Context refers to impaired functions is the primary goal. both the content of what a particular inThis conception of cognitive rehabilitation dividual needs as well as the setting or suggests that "restoration" and "compenphysical environment that the individual sation" are distinct phases of rehabilitaneeds in order to function optimally. tion such that compensatory strategies Decontextualized treatment activities that are not implemented until restorative extake place in artificial environments (setercises have failed. However, it has been tings that are different from those the in- observed that helping TBI individuals to dividual will encounter in the real world) become increasingly aware of their cogand that involve tasks the individual will nitive needs and to be strategic in apnever be called upon to perform may not proaching cognitively demanding tasks constitute effective intervention (Klonoff, (i.e., using a "compensatory" approach) O'Brien, & Prigatano, 1989; Lawson & is actually restorative; that is, this reRice, 1989; Singley & Anderson, 1989). stores the strategic, deliberate aspect of Treatment programs vary depending cognitive processing. Therefore, it is inon the stage of recovery (Adamovich, appropriate to contrast "restorative" and Henderson, & Auerbach, 1985). In the "compensatory" as though they were not early stages of recovery the speech-lanoverlapping approaches. Rather it has guage pathologist directs efforts at elicbeen suggested that these approaches iting and sustaining responses by the should occur simultaneously in rehabilipatient/client. All sensory modalities may tation (M. Ylvisaker, personal communibe used, and the clinician must identify cation, April 1995).
Journal of Speech and Hearing Research
Evidence of the Benefits of Treatment
The literature on the efficacy of cognitive rehabilitation has focused either on the effects of general TBI rehabilitation programs (in which the services of speech-language pathologists are one component) or on specific interventions for discrete deficits (e.g., attention and memory). Findings from several studies concerned with both are summarized below.
program used a general stimulation approach and the other a structured remediation approach focused on attention, spatial integration, and problem solving. Both treatments involved group therapy. Following treatment, both groups of subjects showed significant improvements in cognitive function, suggesting that treatment ina structured setting, with a trained professional and psychosocial group support, has positive effects on cognitive functioning independent of the particular method of treatment.
Rehabilitation programs consisting of general interventions targeting cognitive abilities and community-oriented groups for facilitating appropriate social skills have resulted in improved functioning in subjects with TBI. That is, statistically significant improvements on standardized neuropsychological tests have been noted following treatment (Prigatano et al., 1984). For example, the effectiveness of cognitive retraining for such abilities as attention, memory, and problem- solving skills was investigated by Ruff, Baser, Johnson, and Marshall (1989). Results showed improvements for both a control group of subjects who received training in such areas as health and art and a group of subjects who received cognitive retraining. However, subjects who received memory training showed improvements beyond that of the control group. Harrington and Levandowski (1987) also showed statistically significant improvement on posttest Luria-Nebraska Neuropsychological Battery scores after community-oriented group rehabilitation. Improvements appeared on a variety of neuropsychological functions, including memory. Somewhat mixed findings were reported for a group of TBI individuals enrolled in a post-acute rehabilitation program (Mills, Nesbeda, Katz, & Alexander, 1992). Although cognitive measures were not affected by treatment, there were significant improvements on various functional measures reflecting improvements inhome, community, leisure, and vocational activities. Follow-up at 6, 12, and 18 months demonstrated maintenance of treatment effects. Similarly, Ruff and Niemann (1990) compared two types of cognitive rehabilitation on neuropsychological performance. One
Several studies have reported improved attention following treatment involving auditory and/or visual modules (Ben-Yishay, Piasetsky, & Rattock, 1987) and verbal repetition (Malec, 1984). Success also has been reported with computer-assisted attention retraining (Ruff et al., 1994; Sohlberg & Mateer, 1987). However, some computer-assisted retraining programs have led to significant gains in attentional performance, without generalization of treatment effects (Nieman, Ruff, & Baser, 1990). Finally, performance feedback (Webster, McCaffrey, & Scott, 1986) and reinforcement (Wood, 1986) also have been shown to improve certain aspects of some TBI subjects' attention skills. See Table 1 for a summary of studies focused on improving attention skills. Memory Some degree of memory dysfunction is a consistent finding in most individuals following TBI. Consequently, numerous studies have investigated the possible underlying nature of memory dysfunction in this population. TBI patients/clients may have difficulty retrieving information because of problems with the encoding stage of memory that are due to a decreased ability to generate semantic associations (Levin & Goldstein, 1986) and visual imagery (Richardson, 1984). Therefore, a variety of mnemonic training strategies have been developed in an effort to enhance these associations and images (Crovitz, 1979; Crovitz, Harvey, & Horn, 1979; Gianutsos & Gianutsos, 1979; Wilson, 1987). Several studies also have investigated the effect of simultaneous practice of multiple strategies (Daniel, Webster, & Scott, 1986; Fussey & Tyerman, 1985; Malec &
Questad, 1983; Molloy, Rand, & Brown as cited in Benedict, 1989; Ryan & Ruff, 1988). Details of these studies and others appear in Table 2. Although the findings of these reports are encouraging, a problem common to many memory-retraining approaches and to cognitive rehabilitation programs in general is that of generalization. Most authors agree that after the treatment situation is removed, spontaneous implementation of the learned skill is minimal and many of the skills taught do not improve functional, everyday memory (Lawson & Rice, 1989; O'Connor & Cermack, 1987; Parente & ParenteAnderson, 1989; Schacter & Glisky, 1986). However, there are case studies of memory interventions with TBI individuals in which successful generalization and transfer of trained tasks has been noted-for example, see Lawson and Rice (1989) and Sohlberg and Mateer's (1989b) report on the use a memory book. Recently, also reported to be successful is a computer-based multimedia program for memory retraining (Ruff et al., 1994). Executive Functions Difficulties with executive functions are common afterTBI and are frequently associated with damage to the frontal and prefrontal cortex (Sohlberg, Mateer, & Stuss, 1993). According to Lezak (1982), executive functions comprise those mental capacities necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively. Ylvisaker and Szekeres (1989) note that following severe traumatic brain injury most individuals demonstrate communicative deficits directly attributable to disruption of executive functions. They list a number of dimensions of executive functioning in which this dysfunction may occur, including (a) self-awareness and goal setting, (b) planning, (c) self-direction and initiation, (d) self-inhibition, (e) self-evaluation, and (f) flexible problem solving. It has been suggested that problems with executive functions, more than any other cognitive ability, determine the extent of social and vocational recovery following TBI (Sohlberg & Mateer, 1989a). Self-monitoring procedures (Sohlberg, Sprunk, & Metzelaar, 1988) and verbal and visual feedback (Burke, Zencius, &
Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders
TABLE 1. Summary of a sampling of treatment efficacy studies for deficits of attention resulting from TBI. Study Ben-Yishay, Piasetky, & Rattock (1987)
Orientation Remedial Module, five tasks involving reception of visual and/or auditory stimuli and elicitation of simple visuomotor responses
Subjects progressed from impaired to normal range for all five tasks after training and at 6-month follow-up
Practice with verbal repetition task
Gains inselective attention noted during conversation
Sohlberg & Mateer (1987)
Hierarchy of computer tasks for focused, sustained, selective, alternating, and divided attention
Processing speed and vigilance
Ruff, Mahaffey, Engel, Farrow, Cox, & Karzmark (1994)
Selected tasks tailored to individual's needs using THINKable (computer-based multimedia program developed by IBM) in attention and memory
Performance on computer tasks, psychometric measures, and patient and observer ratings of everyday attention and memory behaviors
Niemann, Ruff, & Baser (1990)
Computer-assisted attention retraining
Attention performance, but no generalization of treatment effects (perhaps due to frontal lobe dysfunction)
Reaction time practice with performance feedback
Reaction time performance
Token reinforcement for selective attention
Selective attention enhanced
Reinforced practice of attention tasks
Gains noted on training tasks; no change on other measures of attention
have described a memory remediation program consisting of both compensatory and executive training skills. The executive strategy training was designed to give individuals practice in the planning and analysis of task demands, in selecting a strategy, in monitoring the course of an activity, and in evaluating the outcome of the activity. This practice led to very encouraging outcomes, which suggest that the functional memory skills of certain TBI individuals can be improved with treatment.
abilities are vulnerable to disruption following TBI. Several studies documenting the effectiveness of social skills training with TBI individuals have appeared in the literature. For example, studies have described the use of videotape feedback (Brotherton, Thomas, Wisotek, & Milan, 1988; Helffenstein & Wechsler, 1982), conversational skills training (Gajar, Schloss, Schloss, & Thompson, 1984; Schloss, Thompson, Gajar, & Schloss, 1985), treatments targeting the reduction of inappropriate speech (Burke & Lewis, 1986; Giles, Fussey, & Burgess, 1988; Lewis, Nelson, Nelson, & Reusink, 1988; Zencius, Wesolowski, & Burke, 1990), pragmatics (Ehrlich & Sipes, 1985), and general social skills (Braunling-McMorrow, Lloyd, & Fralish, 1986). These studies are summarized in Table 4.
Webster, McCaffrey, & Scott (1986) Wood (1986) Wood (1986)
2 2 4
Weslowski, 1991) have been used intraining to improve certain aspects of executive functions (e.g., verbal initiation, response acknowledgment) with reported success (see Table 3 for summaries of these and other studies). Other rehabilitation efforts aimed at improving executive functions in individuals with TBI resemble approaches to metacognitive functioning that have been studied for many years in the field of educational psychology. That literature contains numerous positive reports on the efffectiveness of this type of intervention with learning-disabled children and adolescents. Caution certainly needs to be exercised inmaking cross-population inferences; however, application of this knowledge base to TBI rehabilitation has been discussed by Pressley (1993) and Meichenbaum (1993). The successful incorporation of metacognitive processes into treatment procedures for TBI patients with decreased planning ability and poor self-control and self-monitoring skills also has been reported by Cicerone and Giacino (1992) and Cicerone and Wood (1987). Finally, other authors (Freeman, Mittenberg, Dicowden, & Bat-Ami, 1992)
Social Skills Training Social skills include a variety of abilities (e.g., conversing, sharing, cooperating, greeting others) that enable an individual to interact effectively with peers and with others at home, in school, on the job, and in other environments (Ylvisaker, Szekeres, Haarbauer-Krupa, Urbanczyk, & Feeney, 1992). An individual who is "socially skilled" (a) has knowledge of social rules, roles, and routines; (b) accurately perceives and interprets social cues; and (c) can regulate behavior (M. Ylvisaker, personal communication, April 1995). These
Community Re-Entry Sustained community re-entry at the highest level of productivity, independence, and social adaptation for individual patients/clients is the desired goal of TBI rehabilitation (Malkmus, 1989). Concerns have been expressed about
Journal of Speech and HearingResearch
TABLE 2. Summary of a sampling of treatment efficacy studies for memory deficits resulting from TBI. Study
Crovitz, Harvey, &Horn (1979)
Mnemonic training strategies to improve ability to generate semantic associations
Ability to link stimulus words to visual associations
Gianutsos &Gianutsos (1979)
Word list recall
PQRST strategy (preview material, ask questions, read to answer questions, study information, test for recall)
Recall of written paragraphs was superior with PQRST versus simple rehearsal for immediate and 30-minute recall conditions
Utility of three types visual imagery strategies: rehearsal, clinician-generated, and patient generated
All patients able to use clinician-supplied cues, but only mildly imparied patients could generate their own imagery cues
Fussey & Tyerman (1985)
Simultaneous practice of multiple mnemonic strategies: visual imagery and semantic elaboration
No improvement in memory noted
Molloy, Rand, & Brown (as cited in Benedict, 1989)
Visual imagery and breaking down target visual stimulus into component parts
Increased recall scores
Malec & Questad (1983)
Visual imagery and semantic story elaboration
Gains on Wechsler Logical Memory; no change in word association
Daniel, Webster, & Scott (1986)
Visual imagery and self-instruction
Increased scores on paired associate recall
Ryan & Ruff (1988)
Visual imagery and group intervention
No gains in Wechsler Logical Memory; other improvements dependent on degree of memory impairment
Ruff, Mahaffey, Engel, Farrow, Cox, & Karzmark (1994)
Selected tasks tailored to patient's needs using THINKable (computer-based multimedia program developed by IBM) in attention and memory
Performance on computer tasks, psychometric measures, and patient and oberver ratings of everyday attention and memory behaviors
Sohlberg & Mateer (1989b)
Compensatory memory book
Client learned to use system independently, returned to work, lived in apartment with minimal assistance despite deficits in memory and new learning
Lawson & Rice (1989)
Executive strategy training to improve spontaneous use of verbal recall strategy WSTC: (What am I supposed to be doing? Select a strategy. Try a strategy. Check the strategy.)
Improved recall performance, maintenance of strategy knowledge, and ability to implement novel strategies
the maintenance and generalization of treatment gains demonstrated inclinical settings. Such concerns have risen from research indicating that individuals with TBI often demonstrate chronic memory problems; and those with frontal lobe injuries, in particular, have extreme difficulty spontaneously executing trained strategies or techniques. Functional gains are most easily achieved when cognitive remediation is carried out in the patient's/client's home and community and when such
remediation involves activities of high interest to the individual (Huber & Edelberg, 1993; Kneipp, 1991; Seaman, Roberts, Gilewski, & Nagai, 1993). Further, such treatment enables clinicians to identify skills that appear to be intact or functional in the sterile clinical setting, but are actually nonfunctional in a home or work environment (Starch & Falltrick, 1990). Therefore, communitybased intervention enables clinicians to establish meaningful goals and to evaluate progress. This is certainly consis-
tent with the issue of the context of intervention discussed above. Recently, numerous case reports of treatment intended to enhance daily living, educational, and vocational activities provided by professionals who travel to the TBI individual's home, school, or job have cited positive results with regard to return to school (Blosser & DePompei, 1989; DePompei, & Blosser, 1987) or gainful employment (Brantner, 1992; Kneipp, 1991; Story, 1991; Wehman, 1991; Wehman et al., 1993).
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TABLE 3. Summary of a sampling of treatment efficacy studies for deficits of executive functions resulting from TBI. Study
Sholberg, Sprunk, & Metzelaar (1988)
Self-monitoring procedure for two aspects of executive functions (verbal initiations and response acknowledgment)
Increase over baseline intarget communication behaviors during use of external cues
Burke, Zencius, & Weslowski (1991)
Verbal and visual feedback and various checklists for improving social behaviors, problem solving, and initiation
Upon removal of checklists and feedback trained behaviors were maintained
Cicerone & Wood (1987)
Three-stage training procedure for verbal mediation followed by generalization training with application to real-life problems (decreased planning ability and poor selfcontrol)
Gains noted post-training as well as generalization
Cicerone & Giacino (1992)
Self-instructional technique using Tower of London puzzle as training task
Cicerone & Giacino (1992)
Error-monitoring involving self-recording of errors and analysis of performance on Tower of London puzzle
Improved self-monitoring ability
von Cramon & Matthes-von Cramon (1994)
Generation of alternatives to a problem, analysis of information, practice processing multiple bits of information simultaneously, and drawing inferences
Successful use of technique by an individual with severe frontal lobe dysfunction to the point that he was able to secure supported employment
Freeman, Mittenberg, Dicowden, & Bat-Ami (1992)
Compensatory and executive training
Significantly improved paragraph recall
Individual Differences When the effectiveness of cognitive rehabilitation is evaluated, individual differences among TBI patients/clients must be considered. For example, Ryan and Ruff (1988) noted that attention and memory training was effective for a group of 20 mildly to moderately impaired TBI individuals, but not for a severely impaired group. At the very least, the cognitive rehabilitation programs for more severely involved patients/clients need to be structured differently-with perhaps more intensity, a greater degree of cueing and reinforcement, and longer duration. In addition, without awareness of deficits and motivation, it is difficult to engage an individual with TBI in sustained and effective treatment (BenYishay & Diller, 1993; Haarbauer-Krupa, Szekeres, & Ylvisaker, 1985). Finally, individuals with TBI benefit from programs of cognitive rehabilitation as long after onset as 4 (Cicerone & Wood, 1987) to 6 (Boring, as cited in Benedict, 1989) years. Therefore, time post-onset should not preclude an individual's participation in such a program.
Early Intervention The benefits of early aggressive rehabilitation (including speech-language pathology services) during acute hospitalization following TBI has been quantified by Mackay and colleagues (MacKay, Berstein, Chapman, Morgan, & Milazzo, 1992). Comparison of outcome data for a group of TBI patients/clients who were involved in the early intervention program with a second group who did not undergo this treatment indicated that the early intervention group had significantly shorter rehabilitation stays. Further, the early intervention group was discharged at higher levels of cognitive functioning and had a significantly higher percentage of discharges to home versus extended care facilities. These findings are consistent with previous reports regarding the benefits of early intervention (Cope & Hall, 1982).
Differentiating Treatment Effects and Spontaneous Recovery Given the heterogeneity of TBI, it is extremely difficult to use group designs
to study the efficacy of cognitive rehabilitation. Applications of single-subject designs to cognitive rehabilitation have been described (Franzen & Harris, 1993; Gianutsos & Gianutsos, 1987; Wilson, 1982) and reported by a number of investigators (Gajar et al., 1984; Schloss et al., 1985; Sohlberg & Mateer, 1987; Sohlberg et al., 1988). A multiple-baseline design is particularly well suited for intervention research because it can deal with one of the primary confounding variables in determining the effects of cognitive rehabilitation: spontaneous recovery. Only by demonstrating greater improvement in a trained skill area than in a nontrained skill area can intervention effects be inferred. The multiple-baseline-across-behaviors design allows for this sequential intervention and evaluation (Franzen & Harris, 1993). Furthermore, the use of multiple-baseline designs permits clinicians, in the context of a fee-for-service setting with high productivity expectations, to assess the efficacy of their treatment and appropriately modify their interventions, online, without the need for additional clinical time or cost (Sohlberg, Sprunk, & Metzelaar, 1988).
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TABLE 4. Summary of a sampling of treatment efficacy studies for social skills deficits reulting from TBI. Study
Helffenstein & Wechsler (1982)
Role playing for interpersonal communication skills with videotape feedback
Gains instaff ratings of everyday behavior and observer ratings of two interactions
Brotherton, Thomas, Wisotzek, & Milan (1988)
Individual therapy with role-playing and videotape feedback for posture, speech dysfluencies, self-manipulative behaviors, and low frequency responding
3 of 4 clients maintained improvement at 1-year follow-up; most stable gains were in nonverbal skills; verbal social skills were not maintained at follow-up
Gajar, Schloss, Schloss, & Thompson (1984)
Group discussions and role-played conversations using feedback and selfmonitoring training
Appropriate conversational responses increased to normal range, but dropped when training was discontinued
Schloss, Thompson, Gajar, & Schloss (1985)
Heterosexual conversational interactions, to increase giving compliments, asking questions, and to decrease inappropriate self-disclosures using self-monitoring training
Compliments and questioning increased, but self-disclosures did not decrease
Giles, Fussey, & Burgess (1988)
Conversational skills training to decrease inappropriate behavior and tangentiality using positive and negative reinforcement
Improvements in conversational skills
Zencius, Wesolowski, & Burke (1990)
Visual and verbal feedback to reduce profanity
Profanity decreased inthree settings
Burke & Lewis (1986)
Behavior point system to decrease verbal outbursts, interruptions, and nonsensical talk
Verbal outbursts and interruptions were more responsive to treatment than nonsensical talk
Various types of feedback (attention, ignoring, verbal correction) to decrease impulsive, disinhibited, and inappropriate social behaviors
Client responded best to verbal corrections
Lewis, Nelson, Nelson, & Reusink (1988)
Ehrlich & Sipes (1985)
Pragmatic skills: nonverbal communication, conversation, repairing communication failures, and narrative cohesion using roleplaying and videotape feedback
Greater improvements noted for linguistic skills than nonlinguistic
Braunling-McMorrow, Lloyd, & Fralish (1986)
Situational social skills: compliments, social interaction politeness, criticism, confrontation, and questions and answers using hypothetical situations and gameboard
Improvements noted inappropriateness of mealtime social interactions, but no generalization to other everyday social behaviors
Summary of Program Evaluation Data An intrinsic limitation of all data management systems currently available to speech-language pathologists is that, at present, they are not sophisticated or sensitive enough to measure small increments of functional change. It is with this knowledge that retrospective outcome data were obtained from five wellestablished, fully accredited inpatient rehabilitation programs throughout the United States to determine whether any trends in outcomes could be identified. Each facility provided data for all of their patients/clients with TBI who re-
ceived speech-language pathology treatment in communication and cognition and were discharged during a 12-month period. A variety of commercially available and customized functional status measures were used to determine outcomes by the five reporting facilities. These included the Functional Assessment Measure (FAM, Santa Clara Valley Medical Center, 1993), the Functional Independence Measure (FIM, State University of New York at Buffalo, 1990), the Patient Evaluation and Conference System (PECS, Harvey &Jellinek, 1979), the Rancho Rehabilitation Outcome Evaluation (RROE, Rancho Los Amigos Medical Center, 1993), and the Rehabilitation
Institute of Chicago-Functional Assessment Scales (RIC-FAS, Heinemann, 1993). The two consistent elements in all outcome measurement systems were that each used a 7-point rating scale and that data were obtained on patients/clients at both admission and discharge. Three of the facilities analyzed outcome data by the amount of improvement as determined by the average percentage of gain in functional score. The remaining two sites analyzed outcome data by the average percentage of patients/clients who demonstrated functional improvement. The data provided by the facilities were collected during calendar year 1992 or fiscal year 1992-1993 and
Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders S13 included a total of 444 patients/clients. Not all sites provided information on all outcome measures. The data reported indicate trends and reflect a weighted average that is based on the total number of patients/clients for whom data were available in each area. All facilities reported length of stay (LOS) information. The overall average LOS, based on all 444 patients/clients, was 46.3 days, with a range from 32.5 to 58.4 days across facilities. Variability in LOS is most often associated with factors that include patient/client acuity and cognitive status upon admission, number of co-morbidities, severity of physical involvement, medical complications, age, and length of time from onset to rehabilitation admission. These factors also may affect the severity of the cognitivecommunication disorder. It is important to note that the LOS data do not necessarily reflect the actual need for or length of speech-language treatment program because clinicians traditionally have little influence over LOS within the inpatient rehabilitation setting. Only four facilities reported data related to the discharge placements of their patients/clients. Of the 345 reported discharges, 83.5% (Range: 73.3%/96.2%) were discharged home with or without assistance; 10.7% (Range: 0%-20.0%) were discharged to long-term care facilities; and 5.8% (Range: 3.8%-9.0%) were discharged to other facilities (e.g., acute care settings) because of medical instability and did not return to the comprehensive rehabilitation program. The high percentage of patients/clients receiving speech-language pathology services who returned to the community is consistent with overall rehabilitation industry discharge placement data. Functional outcome data were available for 407 patients/clients in the areas of receptive and expressive language (see Table 5). The amount of improvement, as determined by the average percentage of gain in functional score, involved a sample of 212 patients/clients. The data from the remaining sample of 195 patients/clients were analyzed by the average percentage of functional improvement. With regard to receptive language, an average gain of over 16% in functional score was noted, and an average of approximately 69% of the patients/clients demonstrated functional improvement. For expressive
TABLE 5. Summary of program evaluation data for TBI patients receiving speech-language pathology services from five inpatient rehabilitation facilities. Treatment area
Receptive language Expressive language Speech production Reading Writing Cognition
Amount improvement Average (%) Range (0%) 16.4 17.8 9.7 10.3 11.3 26.1
8.3-22.9 8.6-24.3 7.7-12.6 7.3-14.9 6.9-18
Number patients improved Average (%) Range (%) 69.4 72.7 71 88 77 75
Note. Data on functional outcomes inthe areas of receptive and expressive language represent 407 patients: 212 were analyzed by amount of improvement and 195 by percentage of functional improvement. The speech production data represent 377 patients. Inthe areas of reading and writing, data represent 160 patients: for cognition, the data represent 217 patients. language, an average gain infunctional score of nearly 18% was reported, and an average of approximately 73% of the patients/clients demonstrated improvement. Regardless of measure, the greatest functional improvement was seen in the area of expressive language across all facilities. Four facilities reported speech production data from a total of 377 patients/ clients. The average gain in functional score was approximately 10%. An average of 71% of the patients/clients demonstrated improvement. In the areas of reading and writing, three facilities reported data from 160 patients/clients. For reading, average gain in functional score of over 10% was noted, and an average of 88% of the patients/clients exhibited improvement. For writing, an average gain of approximately 11% in functional score was reported, and 77% of patients/clients demonstrated improvement. Finally, in the area of cognition, only two facilities reported data, which represented 217 patients/clients. An average gain in functional score of 26% was noted, and 75% of the patients/clients demonstrated cognitive improvement. These trends inthe functional improvement of cognitive-communicative abilities (amount of functional improvement, number of patients/clients who improved, and the high percentage of patients/clients discharged home) support the notion that a period of intensive inpatient rehabilitation is beneficial for cognitive-communicative deficits secondary to TBI. All such factors as the amount and rate of recovery, premorbid abilities and status, and cognitive level at the time of admission to reha-
bilitation contribute to variations in the trends reported. It is important to note that these findings have been limited to inpatient rehabilitation. Cognitive-communicative intervention should be provided as necessary along the continuum of care. Data related to the treatment benefits in both the pre- and postrehabilitation settings are needed. With the continued advancement in data management systems, the outcome measurement tools used will become increasingly refined and sensitive in the monitoring of functional change. These systems will allow examination of followup as well as cost/benefit data and their relationship to outcomes and will allow further examination of the long-term effects of speech-language pathology services in the rehabilitation process for patients/clients with TBI.
Summary Several treatment efficacy studies of cognitive rehabilitation were reviewed. Results of these studies indicate that there are a number of treatment techniques that have been successfully applied to deficits of attention, memory, and executive functions in various TBI patients/clients. The heterogeneity of TBI patients/clients prevents the application of a generic treatment approach for this population. For those patients/ clients with more severe cognitive-communicative deficits, treatment may be more effectively directed toward the development of compensatory strategies such as use of memory aids (e.g., appointment book, alarm watch, or a detailed daily schedule). In those indi-
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viduals with profound deficits, treatment may best be focused on environmental modifications or the arrangement of permanent support systems (e.g., training family members/significant others to prompt patient/client during activities of daily living) (Depompei & Williams, 1994; Story, 1991). Single-subject multiple baseline designs are well suited for studying the efficacy of these approaches to cognitive rehabilitation. Interventions directed at specific cognitive deficits are important; nevertheless, clinicians must address broader issues of social skills retraining, timing of treatment during recovery, treatment location and its effectiveness (e.g., hospital, home, school, work). The benefits of early intervention were also stressed. The treatment efficacy findings for TBI patients/clients were also supported by data from five rehabilitation facilities that used various program evaluation systems. Although none of these data management systems are particularly sensitive to small incremental changes, the data revealed that functional gains were realized in receptive and expressive language, speech production, reading, writing, and cognition for TBI patients receiving speech-language treatment. The cost/benefit of cognitive rehabilitation is supported by the findings of Aronow (1987), who noted that inpatients receiving rehabilitation services returned to productive living at the same rate as a
less severely injured group who had not received treatment. Furthermore, when patients/clients with similar severity of disabilities were compared, those who had received rehabilitation had better average cost outcomes than those not receiving rehabilitation services. Finally, future research regarding the treatment efficacy of cognitive-communicative disorders resulting from TBI should address the following issues: (a) representativeness of the TBI subjects (i.e., most of the studies completed to date have excluded very severely impaired individuals or those with marked behavioral problems), (b)identification of subgroups of TBI patients with very specific rehabilitation needs, and (c) broadened criteria for a successful outcome from cognitive rehabiliation to include quality-of-life indices such as family relationships and leisure activities. Acknowledgments The authors wish to thank those individuals who provided feedback on the initial draft of this article: Brenda L.B.Adamovich, Roberta DePompei, Danese Malkmus, McKay Moore Sohlberg, and (inparticular) Mark Ylvisaker for his extensive comments. Cynthia Thompson and two anonymous reviewers provided several excellent suggestions for revising an earlier version of this article.
References Adamovich, B.L.B. (1991). Cognition, language, attention, and information processing
Background Milton (1988) described a 35-year-old man, a bank vice president, who was involved in a motorcycle accident that resulted in a severe TBI. He was comatose for 5 weeks. After 4 months of comprehensive inpatient rehabilitation he had no physical impairments but was left with subtle cognitivecommunicative deficits.
following closed head injury. InJ. S.Kreutzer & P. H.Wehman (Eds.), Cognitive rehabilitation forpersons with traumatic brain injury (pp. 75-86). Baltimore: Paul H.Brookes Pub. Adamovich, B. L. B., Henderson, J. A., & Auerbach, S. (1985). Cognitive rehabilitation of closed head injured patients. San Diego: College Hill Press. Alexander, M.P., Benson, D.F., &Stuss, D. T.(1989). Frontal lobes and language. Brain and Language, 37, 656-691. American Congress of Rehabilitation Medicine. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8,86-87. American Speech-Language-Hearing Association. (1987). The role of speech-language pathologists in the habilitation of cognitively impaired individuals: Areport of the subcommittee on language and cognition. Asha, 29, 53-55. American Speech-Language-Hearing Association. (1990). Guidelines for speech-language pathologists serving persons with language, socio-communicative, and/or cog- nitive-communicative impairments. Asha, 32,85-92. Aronow, H.V.(1987). Rehabilitation effectiveness with severe brain injury: Translating research into policy. Journal of Head Trauma Rehabilitation, 2, 24-36. Benedict, R.H. B.(1989). The effectiveness of cognitive remediation strategies for victims of traumatic brain injury: A review of the literature. Clinical Psychology Review, 9,605-626. Ben-Yishay, Y., & Diller, L.(1993). Cognitive remediation in traumatic brain injury: Update and issues. Archives of Physical Medicine and Rehabilitation, 74, 204-213. Ben-Yishay, Y., Piasetsky, E.B., & Rattock, J. (1987). A systematic method for ameliorating disorders inbasic attention. InJ.M.Meier,
performance evaluation tool, identification of problem areas and possible solutions, development of a design strategy, intensive practice, and refinement. Responsibility for applying strategies and results was gradually shifted from the clinician to the patient/client.
Outcome The patient/client returned to full-time employment at 9 months post-onset after 5 months of specialized assistance.
This individual then was enrolled in a rehabilitation program designed to return him to work. Treatment sessions were conducted by a speech-language pathologist at home and at work; his wife, work supervisor, and secretary assisted in the treatment sessions. The process involved observation of the patient/client at work, development of a
Coelho et al.: Treatment Efficacy in Cognitive-Communicative Disorders S15 A. L. Benton, & L. Diller (Eds.), Neuropsychological rehabilitation (pp. 165-181). New York: Guilford Press. Blosser, J. L., & DePompei, R. (1989). The head injured student returns to school: Recognizing and treating deficits. Topics in Language Disorders, 9, 19-32. Braunling-McMorrow, D., Lloyd, K., & Fralish, K. (1986). Teaching social skills to head injured adults. Journal of Rehabilitation, 52, 39-44. Brantner, C. L. (1992). Job coaching with persons with traumatic brain injuries employed in professional and technical occupations. Journal ofApplied Rehabilitation Counseling, 23, 3-14. Brotherton, F.A., Thomas, L. L., Wisotzek, I. E., & Milan, M. A. (1988). Social skills training in the rehabilitation of patients with traumatic closed head injury. Archives of Physical Medicine and Rehabilitation, 69, 827-832. Burke, W. H., & Lewis, F. D. (1986). Management of maladaptive social behavior of a brain injured adult. International Journal of Rehabilitation Research, 9, 335-342. Burke, W. H., Zencius, A. H., Weslowski, M. D. (1991). Improving executive function disorders in brain-injured clients. Brain Injury, 5, 241-252. Cicerone, K. D., & Giacino, J. T. (1992). Remediation of executive function deficits after traumatic brain injury. Neuropsychological Rehabilitation, 2, 12-22. Cicerone, K. D., &Wood, J. C. (1987). Planning disorder after closed head-injury: A case study. Archives of Physical Medicine and Rehabilitation, 68, 11-115. Cope, D. N., & Hall, K. H. (1982). Head injury rehabilitation: Benefit of early intervention. Archives of Physical Medicine and Rehabilitation, 63, 433-437.
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Kreutzer, Wehman, Conder, and Morrison (1989) reported success with TBI patients/clients. One individual, a man in his thirties, sustained a moderate head injury in a motorcycle accident. Within one month post-injury he had recovered physically but continued to demonstrate significant problems with memory, attention, reasoning, and organization, as well as difficulty controlling his temper. He subsequently had to give up his free-lance photography and college teaching; instead he turned to painting and home renovation. A major problem for this individual was organizing his work schedule. He often took more jobs than he could handle and received many complaints from customers about delays in job completion.
The clinician established a plan to improve the timeliness of his work by using a log that listed each job, the expected duration of the job, and projected completion date. In addition, new jobs were accepted and scheduled on a tentative basis and only finalized after consulting with his wife, estimating completion times liberally, and working on one job at a time.
Outcome This process relieved a great deal of the man's stress. Eventually he completed his master's degree, and although he continued to work part-time as a contractor he resumed freelance photography and began looking for part-time teaching positions. He and his clinician were also working on organizational strategies intended to improve his teaching skills.
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