Treatment section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The goal of intervention in traumatic brain injury (TBI) is to achieve the highest level of independent function for participation in daily living. Consistent with the ICF framework (World Health Organization, 2001), intervention is designed to
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
- facilitate the individual's activities and participation by assisting the person in acquiring new skills and strategies;
- modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including development and use of appropriate accommodations.
Interventions that enhance a patient's activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited.
Treatment of individuals with TBI is individualized and typically considers the influence of
- the complex relationship between cognitive domains (e.g., an individual with short-term memory impairments who is unable to recall names may also have attention deficits that negatively influence this individual's ability to attend to and encode newly presented information);
- fatigue and limited physical endurance impacting duration of participation in treatment;
- personal and contextual factors, such as the individual's age, education, premorbid status, social history, present social context, cultural and linguistic background, and vocational status (current or premorbid);
- physical, sensory, and neurobehavioral sequelae of TBI, especially in the acute phase of recovery;
- poor insight into deficits (anosagnosia) and executive function impairments that may negatively influence recognition of breakdowns in function, buy-in to potential benefits of treatment, and adherence to specific recommendations (for example, individuals may fail to follow swallow safety guidelines, wear hearing assistive technology, or follow safety recommendations).
Treatment is provided in the language(s) used by the individual and considers the cultural values and norms of the individual. See
bilingual service provision and
cultural competence. In addition, treatment typically involves
- focusing on functional and meaningful outcomes while including the individual with TBI in collaborative decision making about self-determined and self-paced intervention activities, as appropriate (Malec, 1996);
- the collaborative efforts and input from the individual and caregivers, physicians, audiologists, psychologists, physical and occupational therapists, and other professionals involved in the care of the individual;
- strengthening intact cognitive skills and communication modalities and behaviors to support and augment functional independence in activities of daily living;
- compensating for cognitive-communication impairments by teaching compensatory strategies to support the individual and his/her family;
- training use of a multimodal communication system (e.g., spoken language, gestures, sign language, picture communication, speech-generating devices [SGDs], and/or written language) that is customized according to the individual's abilities and the contexts of communication;
- training family and caregivers to effectively communicate with persons with TBI using supports and strategies, in order to maximize communication competence;
- educating persons with TBI, their families, caregivers, and other significant persons about the nature of deficits, the course of treatment, and prognosis for recovery;
- measuring progress using systematic methods to determine whether an individual with TBI is benefiting from a particular treatment program or strategy;
- considering the individual's and family's priorities when selecting intervention goals-meaningful outcomes are correlated with functional goals resulting in improved independence, generalization, and communication competence across social contexts (e.g., home, school, vocational, and community settings).
The following are brief descriptions of both general and specific treatments for persons with cognitive-communication and swallowing disorders associated with TBI. Where available, links to evidence and expert opinion regarding interventions are provided. This alphabetized list is not exhaustive, and inclusion of any specific treatment approach does not imply endorsement by ASHA.
Cognitive-communication treatment approaches in TBI focus either on restoration of skills or compensation for deficits. Treatments can also be specific to retraining discrete cognitive processing components (e.g., attention process training; Sohlberg & Mateer, 1987) or retraining more integrative abilities and functional skills (e.g., ordering from a menu; Mayer, Keating, & Rapp, 1986). Finally, treatment approaches can also be either "bottom-up" (training basic skills to build up to more complex processing) or "top-down" (training complex skills to strengthen underlying basic skills). Many approaches fall into overlapping categories, and clinicians use whichever approach or combination of approaches meets the needs and values of each individual with TBI.
Instructional methods may facilitate active learning via declarative memory (e.g., imagery, verbal elaboration) or passive learning via implicit memory (e.g., errorless learning, hierarchical cueing). Instructional methods can be either forms of direct instruction (e.g., breaking the target into discrete steps and sequentially completing a task) or strategy-based training (e.g., training the individual to develop internal strategies that enable him/her to perform complex tasks). These are supported by different levels/types of cueing and practice dosage. Selecting appropriate treatment approaches based on the principles of instruction facilitates more efficient learning of skills and strategies (Ehrlhardt et al., 2008).
Compensatory Strategy Training
Compensatory strategy training focuses on maximizing the skills of the individual with TBI by either modifying the environment and/or providing internal and external supports (Shum, Fleming, Gill, Gullo, & Strong, 2011)and capitalizes on intact skills to overcome deficits resulting from TBI (Wilson, 2002). Compensatory strategies can include both internal (e.g., mnemonics, imagery, association) and external (e.g., memory aids, PDAs, calendars) strategies. External strategies involving assistive technology may support a variety of cognitive-communicative impairments, including attention, memory, navigation, time management, organization, and emotional function (Sohlberg et al., 2007; de Joode, van Heugten, Verhey, & van Boxtel, 2010; Gillespie, Best, & O'Neill, 2012; Wild, 2013).
Computer-Assisted Treatment (CAT)
Available as commercial software or mobile applications, computer assisted treatment (CAT) typically consists of repeated trials targeting specific skills or functional tasks that adapt to the individual's performance. This ensures that "the speed and complexity of the exercises increase as the user's performance improves in order to consistently maintain a high proportion of successful trials while stimulating the brain with gradually more demanding tasks" (Lebowitz, Dams-O'Connor, & Cantor, 2012). Used as an adjunct to clinician-moderated skilled treatment, CAT can be used to treat a number of domains of cognitive-communication deficits by providing consistent feedback to the individual. See considerations for
selecting technology or related treatment products.
Drill And Practice Training
Repetitive drills focus on practice of newly learned skills and aim to stimulate damaged neural networks or establish new networks to restore a specific skill (e.g., repeated practice to learn scripts for maximizing conversational competence; Shum et al., 2011). Spaced retrieval is the successful retrieval of information repeatedly over durations of time increasing in length. Although spaced retrieval is most commonly discussed in the literature relative to dementia, it may be used in the TBI population and accompany drill and practice training to promote carryover.
Dual Task Training
Dual task training focuses on improving task complexity by targeting the ability to carry out two competing tasks (typically requiring equal amounts of attention) simultaneously. The tasks may involve a combination of two cognitive tasks, a cognitive and motor task, or two motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009).
Errorless learning is a treatment method in which the SLP precludes the person with TBI from making errors during the learning acquisition phase of any targeted skill (Ownsworth et al., 2013). "Elimination of errors is achieved by (1) breaking down the targeted task into small, discrete steps or units; (2) providing sufficient models before the client is asked to perform the target task; (3) encouraging the client to avoid guessing; (4) immediately correcting errors; and (5) carefully fading prompts" (Sohlberg, Ehlhardt, & Kennedy, 2005, p. 272). Errorless learning has been found to be most beneficial for those individuals with relatively unimpaired procedural memory and severely impaired declarative memory. High amounts of correct practice, distributed practice, forward-and-backward chaining, and effortful processing have been found to facilitate errorless learning (Sohlberg et al., 2005). Commonly used treatment methods, such as spaced retrieval (Melton, Bourgeois, 2005; Haslam, Hodder, & Yates, 2011) and method of vanishing cues (Sohlberg et al., 2005), are based on principles of errorless learning.
Metacognitive Skills Training
Metacognitive skills training focuses on improved deficit awareness, self-monitoring, and self-regulation in order to facilitate better recognition of problem situations and identification of functional strategies that facilitate success in achieving everyday goals (Cicerone, 2006).
Also known as coma stimulation, sensory stimulation is the systematic exposure of an individual in a comatose, vegetative, or minimally conscious state to a variety of environmental stimuli (visual, auditory, tactile, olfactory, and kinesthetic) to improve arousal/level of consciousness (Giacino, Katz, & Schiff, 2006). Coma stimulation aims to prevent sensory deprivation, which may influence recovery (Thomas, 2013) and allows for frequent monitoring of an individual's responsiveness during recovery.
Interventions designed to improve functional conversational skills (e.g., taking turns, remaining on topic) can be helpful navigating social situations for individuals with traumatic brain injury. Important components of social communication intervention in adults with traumatic brain injury include
- sharing knowledge with and training everyday communication partners,
- selecting highly specific and personal goals and incorporating extensive practice of social behaviors in the situations in which they are required,
- situational coaching prior to challenging situations,
- situational training to improve social perception and interpretation of others' behaviors to improve self-monitoring of stress,
- focusing on social success,
- counseling to help an individual identify a sense of self that includes positive social interaction strategies.
(Ylvisaker, Turkstra, & Coelho, 2005)
Treatment of speech production deficits in TBI may focus on individual speech subsystems or more globally on speech intelligibility, using behavioral and instrumental treatments, compensatory strategies, and/or environmental modifications. Behavioral treatment of dysarthria includes "active exercises (e.g., strength training), stretching (e.g., to increase or decrease tone), passive exercises (e.g., massage to relax musculature), and the use of physical modalities such as heat (to reduce pain), cold (to reduce spasticity) and electrical stimulation (to elicit voluntary contractions)" (Murdoch & Wheelan, 2006, p. 870). Instrumental biofeedback via auditory, visual, or tactile modalities may also be used to augment treatment outcomes in individuals with TBI.
Augmentative and alternative Communication (AAC)
AAC involves supplementing or replacing natural speech and/or writing with aided (e.g., pictures, line drawings, speech-generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Whereas aided symbols require some type of transmission device, production of unaided symbols only requires body movements. Factors such as communication abilities and needs-as well as cognitive, neurobehavioral, motor, sensory, and perceptual impairments of the individual following TBI-influence selection and use of appropriate AAC systems. Individuals with TBI may rely on assistive technologies for complex communication needs in the absence of linguistic or motor speech disorders in order to compensate for their cognitive impairments (Fried-Oken, Beukelman, & Hux, 2011). See ASHA's Practice Portal page on Augmentative and Alternative Communication (AAC).
Considerations for dysphagia management in individuals with TBI include
- the impact of cognitive-linguistic deficits, such as auditory processing and memory loss that may impact learning, recall, and use of compensatory strategies to maximize swallow safety;
- neurobehavioral deficits (e.g., impulsivity, agitation);
- perceptual deficits, such as visual field neglect;
- physical limitations impacting motor control and postural maintenance;
- sensory impairments impacting swallow safety and oral intake.
Dysphagia management must consider the consistent implementation of compensatory strategies and diet modification given the frequent deficits in cognition and learning in individuals with TBI (Cherney & Halper, 1996).
See ASHA's Practice Portal page on Adult Dysphagia.
Hearing and Balance
Audiologists are integral to rehabilitation of hearing and balance deficits associated with TBI. Treatment for hearing loss includes selection and fitting of amplification devices and assistive technologies, as well as education regarding use and realistic expectations of these systems. Intervention also incorporates counseling regarding coping and compensatory skills to minimize the effects of hearing impairment.
The treatment goal of balance disorders associated with TBI is to promote natural central compensation processes of the vestibular system that reduce or eliminate symptoms, thereby reducing fall risk by improving static and dynamic balance as well as gait competence.
The nature of deficits associated with TBI creates unique challenges for patients returning to the community and/or work environment following injury. Deficits in pragmatic language, attention, and memory are among the factors that may negatively impact performance in social and professional settings.
The SLP identifies current communication deficits and if and how they may affect job performance and provides or trains rehabilitation strategies to minimize the impact of those deficits in functional settings (Bonelli, Ritter, & Kinsler, 2007).
The SLP collaborates with a vocational rehabilitation therapist as appropriate. Assessing a functional skill in context and then treating that skill in context, as has been done in the field of vocational rehabilitation, may result in better outcomes.
Service Delivery section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for individuals with TBI, SLPs consider other service delivery variables-including format, provider, dosage, and timing-that may impact treatment outcomes.
Format refers to the structure of the treatment session (e.g., group vs. individual) provided. Group therapy may target cognitive domains and provide individuals with TBI an opportunity to initiate social interaction in a structured environment with feedback from the clinician and peers.
Combined individual and group therapy are more effective in reaching goals of functional improvement, including those related to executive function and problem solving, than group format alone (Tate et al., 2014). Training that incorporates everyday communication partners may be successful and allow partners to facilitate carryover beyond the training sessions, while standardized social skills training may not generalize to other contexts (Togher et al., 2014).
Because of the ongoing need for services for patients with TBI, the training and education needs of caregivers, and the difficulty in accessing SLPs skilled in TBI service provision, telepractice services may be appropriate to meet the need of some patients and caregivers. Telepractice may not only improve functional ability of the patient following discharge, but also have positive outcomes for the psychological wellbeing, support skills, and the level of burden on caregivers in a functional environment (Rietdijk, Togher, & Power, 2012). Videoconferencing and interactive skills-based programs via telepractice may be more meaningful for providing support and information to caregivers than self-guided web sessions (Rietdijk et al., 2012). Telepractice may allow clinicians to provide opportunity for patients to practice skills in the context in which they will be used (Turkstra, Quinn-Padron, Johnson, Workinger, & Antoniotti, 2012).
Provider refers to the person offering the treatment (e.g., SLP, trained volunteer, caregiver). Cognitive rehabilitation is most successful when contextualized within the individual's current living environment and needs. The brain injury survivor's family and significant others play a critical role in supporting and augmenting the treatment plan. If rehabilitation is delivered in part through modifications and supports in the everyday routines of life, the participants in those routines (e.g., significant others) may need considerable training and coaching from specialists to play their role effectively.
Dosage refers to the frequency, intensity, and duration of service. Clinicians consider individual's arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity when determining the appropriate frequency, intensity, and duration of services.
Setting refers to the location of treatment (e.g., home, community-based). Clinicians consider the individual's functional ability, goals, and opportunities to facilitate carryover in determining the most appropriate setting for intervention.