Speech-Language Pathologists (SLP) in an Outpatient Setting
Once the individual with TBI is referred to speech therapy services in an outpatient setting, the SLP first conducts an evaluation of the individual's speech, language and cognitive skills. The SLP selects among a variety of formal tests that best correspond to the individual's medical background; one of the tests oftentimes used to evaluate a patient's cognitive skills is the Woodcock-Johnson Test of Cognitive Abilities (WJ-III).
Formal test results are combined with qualitative observations during the speech therapy meetings. It is important to note that the patient's hopes and goals for speech therapy are at least as important as formal testing since the overall goal is to increase the patient's quality of life and daily functioning.
In an outpatient rehabilitation setting such as Spaulding Rehabilitation Hospital, Speech-Language Pathologists primarily focus on a cognitive-linguistic therapy approach to compensate and/ or restore cognitive impairments when treating people with brain injury.
In general, cognitive functions refer to what and how much knowledge, skill and intellectual equipment a person may possess. Cognition encompasses a brain's mental input and output and ranges from activities such as using language to complex decisions, creativity as well as a person's ability to understand things from another person's perspective.
Cognitive Rehab refers to the therapeutic process of increasing or improving an individual’s capacity to process and use incoming information so as to allow increased functioning in everyday life.
It is directed to achieve functional change by:
It is important to note that an injured brain is capable of learning new behaviors due to its neuroplasticity; however, the learning process may be slower post-injury and the error rate may be higher.
Cognitive-linguistic therapy:
Functionality
One of the most crucial parts of cognitive-linguistic therapy is to always incorporate functional and meaningful tasks during treatment, which will enhance the patient's quality of life by increasing his/ her level of independence. For example, a person may have difficulties with paying bills online due to the many steps that are involved in planning and executing the task such as locating the appropriate website, logging in, and paying the accurate amount of money.
Attention
Attention training is helpful in the post-acute period of recovery. It
does not restore underlying processes, but allows patients to apply compensatory strategies that they can use to facilitate attention and concentration. For example, they may learn to monitor their fatigue by taking frequent breaks during cognitively- demanding tasks, prevent multi-tasking and eliminate and/or minimize distractions in their environment by making conscious adaptations such as sitting in the corner of a restaurant versus the center to avoid environmental distractions. In addition, the patient has to be made aware that he/she should work on one task at a time rather than multitasking.
Memory
Patients with prospective memory impairments may benefit from: external memory compensation such as memory notebooks, daily planners and calendars, which allow patients to keep track of appointments, tasks and other errands. The SLP oftentimes demonstrates ways to effectively utilize planners, so that patients do not forget certain appointments and learn to effectively monitor the progress of their tasks.
external cueing and environmental compensation:
these may include portable voice organizers, NeuroPage paging services and ISAAC cognitive prosthetic systems. Such compensatory devices are frequently used to remind patients of taking medications and daily household activities (making lunch, taking a shower, doing the laundry).
Additional strategies that may be addressed during speech therapy may include:
There are various online resources that are useful for patients with traumatic brain injury since they involve attention and memory skills.
Executive Functioning:
Pragmatic Skills
TREATMENT STRATEGIES
Oftentimes, patients are asked to free-write for 10-15 minutes a day, which is based on “writing down the bones” by Natalie Goldberg.
The principles of this activity include:
1) Keep your hands moving (don’t pause)
2) Don’t cross out
3) Don’t worry about spelling, punctuation, grammar
4) Lose control
5) Don’’t think. Don’t get logical.
6) Go for the jugular.
This activity has advantages for the writer (patient):
Group Treatment
Group treatment may be beneficial for patients with brain injury. They allow patients to exchange information and experiences with one another, thereby allowing them to socialize with others who are affected by similar situations. It may help patients realize that they are not alone with their particular difficult situation. Besides receiving advice from others, group treatment also allows patients to help others and to generate ideas and plans.
Recovery
Once the individual with TBI is referred to speech therapy services in an outpatient setting, the SLP first conducts an evaluation of the individual's speech, language and cognitive skills. The SLP selects among a variety of formal tests that best correspond to the individual's medical background; one of the tests oftentimes used to evaluate a patient's cognitive skills is the Woodcock-Johnson Test of Cognitive Abilities (WJ-III).
Formal test results are combined with qualitative observations during the speech therapy meetings. It is important to note that the patient's hopes and goals for speech therapy are at least as important as formal testing since the overall goal is to increase the patient's quality of life and daily functioning.
In an outpatient rehabilitation setting such as Spaulding Rehabilitation Hospital, Speech-Language Pathologists primarily focus on a cognitive-linguistic therapy approach to compensate and/ or restore cognitive impairments when treating people with brain injury.
In general, cognitive functions refer to what and how much knowledge, skill and intellectual equipment a person may possess. Cognition encompasses a brain's mental input and output and ranges from activities such as using language to complex decisions, creativity as well as a person's ability to understand things from another person's perspective.
Cognitive Rehab refers to the therapeutic process of increasing or improving an individual’s capacity to process and use incoming information so as to allow increased functioning in everyday life.
It is directed to achieve functional change by:
- establishing or reinforcing previously learned patterns of behavior
- establishing new patterns of cognitive activity through compensatory cognitive mechanisms
- establishing new patterns of activity through external compensatory mechanisms, which refer to strategies where procedures or assistive devices are used to overcome impairments that cannot be modified.
- enabling persons to adapt to their cognitive disability to improve overall functioning
It is important to note that an injured brain is capable of learning new behaviors due to its neuroplasticity; however, the learning process may be slower post-injury and the error rate may be higher.
Cognitive-linguistic therapy:
Functionality
One of the most crucial parts of cognitive-linguistic therapy is to always incorporate functional and meaningful tasks during treatment, which will enhance the patient's quality of life by increasing his/ her level of independence. For example, a person may have difficulties with paying bills online due to the many steps that are involved in planning and executing the task such as locating the appropriate website, logging in, and paying the accurate amount of money.
Attention
Attention training is helpful in the post-acute period of recovery. It
does not restore underlying processes, but allows patients to apply compensatory strategies that they can use to facilitate attention and concentration. For example, they may learn to monitor their fatigue by taking frequent breaks during cognitively- demanding tasks, prevent multi-tasking and eliminate and/or minimize distractions in their environment by making conscious adaptations such as sitting in the corner of a restaurant versus the center to avoid environmental distractions. In addition, the patient has to be made aware that he/she should work on one task at a time rather than multitasking.
Memory
Patients with prospective memory impairments may benefit from: external memory compensation such as memory notebooks, daily planners and calendars, which allow patients to keep track of appointments, tasks and other errands. The SLP oftentimes demonstrates ways to effectively utilize planners, so that patients do not forget certain appointments and learn to effectively monitor the progress of their tasks.
external cueing and environmental compensation:
these may include portable voice organizers, NeuroPage paging services and ISAAC cognitive prosthetic systems. Such compensatory devices are frequently used to remind patients of taking medications and daily household activities (making lunch, taking a shower, doing the laundry).
Additional strategies that may be addressed during speech therapy may include:
- listening to news articles (accessed via npr) and asking the patient to provide the main idea as well as details
- writing things down and keeping a record of important events, people's names, tasks or other things that are difficult to remember
There are various online resources that are useful for patients with traumatic brain injury since they involve attention and memory skills.
- set game
- KenKen
- Posit Science
- Happy Neuron
- Lumosity
- APPS (calendar, alarms, banking, bill paying, find your car/ phone)
Executive Functioning:
- patients may have goal neglect: the tendency to disregard the requirements of a given task, even when requirements are verbally appraised
- involves the evaluation of relevant goals in a situation, selection of sub-goals, then monitoring the results of one’s attempt at a solution
- thus, if the patient has a goal such as starting his/her own private practice, the patient may be prompted to break this overall goal into multiple steps
- the patient may also be cued to formulate corresponding tasks and deadlines for each step and to "translate the plan into action"
Pragmatic Skills
- some patients with TBI may exhibit a less cohesive narrative discourse and may also have difficulty with interpreting subtle, contextual aspects of social communication (e.g., humor, irony)
- thus, the SLP may provide patient with systematic feedback, and training of self-monitoring
- conversations may be recorded so that the patient has direct feedback regarding his/ her performance and to assess his/ her initiation, topic maintenance and turn taking skills.
TREATMENT STRATEGIES
Oftentimes, patients are asked to free-write for 10-15 minutes a day, which is based on “writing down the bones” by Natalie Goldberg.
The principles of this activity include:
1) Keep your hands moving (don’t pause)
2) Don’t cross out
3) Don’t worry about spelling, punctuation, grammar
4) Lose control
5) Don’’t think. Don’t get logical.
6) Go for the jugular.
This activity has advantages for the writer (patient):
- self-generated ideas provide direction
- compensate for memory loss/ provides thread of continuity
- allows recognition of process through review
- improves understanding of focus of treatment program in relation to personal goals
- allows insight and understanding
- elicits different content from verbal dialogue
- improves understanding of patient concerns
- aids planning of meaningful treatment
- indicator of patient degree of insight/ acceptance
- encourages patient initiation/ pt participation
Group Treatment
Group treatment may be beneficial for patients with brain injury. They allow patients to exchange information and experiences with one another, thereby allowing them to socialize with others who are affected by similar situations. It may help patients realize that they are not alone with their particular difficult situation. Besides receiving advice from others, group treatment also allows patients to help others and to generate ideas and plans.
Recovery
- usually, cognitive deficits are most severe immediately following the brain injury and show an improving course thereafter. Research has shown that recovery is rapid in the six months to one year post-injury, and that progress continues at a slower pace for the next one to three years