Traumatic Brain Injury: Are you

interested?February 5, 2011

TBI: What SLPs Should Know

• The Speech Language Pathologist’s (SLP)s role in working with patients with Traumatic Brain Injuries (TBI)

• Lower level patients• Higher level patients• Family involvement

Linda Hertz ShivelyMA CCC SLP

• Kentfield Rehab and Specialty Hospital • Per diem work at about 10 hospitals• Transitions of Berkeley/Learning Services

at Berkeley• The Greenery Rehab Hospital

Traumatic Brain Injury:

–Strokes•Focal damage•Blockage or break in an artery

Traumatic Brain Injury: Diffuse Damage

Point of impactContra coup damageTwisting of the brain stemSheering on the sinusesSwelling

Traumatic Brain Injury: Age

o Neuroplasticity of the braino Motivationo “The parents” vs. “My child”o Larger support system

Traumatic Brain Injury: The Result

Communication

Cognition

Rancho Los Amigos Cognitive Scale -Revised

Lower levels vs.

Higher levels

Rancho Los Amigos Cognitive Scale -Revised

Level one: No response: Total Assistance•To stim•To painful stim

Rancho Los Amigos Cognitive Scale -Revised

Level Two: Generalized Response: Total Assistance –Generalized Response–Spontaneous movement

Rancho Los Amigos Cognitive Scale -Revised

Level Three: Localized Response: Total Assistance –Localized Response–Beginning to follow commands–Spontaneous movements–Reflexes

SLP’s role:

–Personally relevant–Differentiate between Spontaneous

vs. Volitional–Improvement = therapy time–Educate other Professionals–Family

Volitional and Spontaneous Movements: Difficulty in Assessment

1. Spontaneous movement2. Roving eye movements3. Not motorically capable4. Reduced attention 5. Distractible to environment

Volitional and Spontaneous Movements: Difficulty in Assessment

6. Reflex7. Delayed responses8. Apraxia9. Saturated10. Seizures

How to Assess Volitional vs. Spontaneous Movement

–The patient must be alert

How to Assess Volitional vs. Spontaneous Movement

• Standardized Tests: Western NeuroSensory Stimulation Profile (WNSSP)• 113 point scale: • great for showing incremental changes• attn, generalized vs. localized responses

to stimulation, visual tracking, oral reflexes

How to Assess Volitional vs. Spontaneous Movement

• Structured observationCompare:– quiet environment –vs. general stimulation –vs. commands

•Change the order daily• Same amount of time

Kentfield Structured Observation Chart

Rancho Los Amigos Cognitive Scale -Revised

Level 4: Confused/Agitated: Maximal Assistance Behaviors:• Alert and very motor restless• Purposeful attempts to remove tubes,

crawl out of bed, etc.• Fleeting attention with no memory or

controlMay be receptive to basic non-language info

Rancho Los Amigos Cognitive Scale -Revised

Level 4: Confused/Agitated: Max. Assist.SLPs role

• Help them get through• Tell and model to the family (and other

profs)–Calm voice–Body language–Facial expression–Re-assurance yet Treat them age

appropriately

Rancho Los Amigos Cognitive Scale -Revised

Level 5: Confused, Inappropriate Non-Agitated: Maximal Assistance–Cognition is jumbled up

Functional Memory:The Day Planner

Why? – Improves Memory– Improves reasoning– Organization– Landmarks of improvement– Can address impulsivity – Left neglect and reading and writing skills– To live independently

The Day Planner

Schedule Section • Page per day (already dated)• Keep old pages: as a journal• “Today” Book mark

The Day Planner

Therapy section–Speech homework–PT and OT–Goals

The Day Planner

Personal Section–Phone numbers–Info from the doctor–Journal–Get well cards–Whatever – it’s theirs!

The Day Planner

Paper Section• Keep it blank!

The Day Planner Concepts

–Ring binder, not spiral bound –Pencil–Keep it organized (daily)–If you want a calendar page–Habitualize it When should the pt. take

it with them?–“Day Planner” vs. “Memory Book”

The Day Planner

• The Family’s role: –Enter the schedule–“What’s next?”–“How are you going to remember

that?” not “Write that down”

Cognition

• Personally relevant• Lists for generative naming, category

exclusion, sentence completion, make a crossword puzzle• Simple problem solving questions

Pragmatics

–Facial affect• EACH facial feature

–Intonation• “My new blue jacket”

–Social appropriateness• For different (concrete) settings

Rancho Los Amigos Cognitive Scale -Revised

Level 6: Confused, Appropriate, Moderate Assistance…and beyond

Day Planner: Menu’s1. Cognitive Tasks: answer email, plan

an outing, make a shopping list 2. Physical Tasks: shoot baskets, walk on the beach, walk the mall3. Household Chores: water house plants, fold laundry, set table, feed

the dog, dust, sort the mail4. Fun Activities: TV, play music, call a

friend, read: book, mag., newspaper

Executive Functioning

What executives do: –Multi-task:–Divide attention:–Organize:–Prioritize:

Executive Functioning

–See the big picture:–See the details:–Comprehend the consequences:–Teach structures: “recipes”

Beyond Workbooks:

What does the patient need to do? What do YOU do?

–Meal plan: menu/ Food list/ utensils-equipment

Meal Plan

MENU FOOD UTENSILS Spag. *noodles noodle pan

*oil sauce pansauce colanderParm. Chees big spoon

bowl Salad *lettuce cutting board

tomato knife etc…….

Beyond Workbooks:

What does the pt. need to do?

–Orchestrate a meal–Transportation: bus–Budget–What to take to school–Getting Assist. in stores

Beyond Workbooks:

What does the patient want?• Driver’s license• Date• Go to school• Have fun

Family

–Educate along the way–Listen to them–Model• “I Statements” and model for them: “I

feel scared when you start walking in the street without looking” not “YOU have bad judgment”

Bottom line:

THEIR interest =

YOUR therapeutic success!