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Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury. Jessica D. Richardson, Ph.D., CCC-SLP. ASHA Scope of Practice. ASHA = American Speech-Language-Hearing Association

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Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury

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Role of the speech language pathologist in the recovery process of individuals with traumatic brain injury

Role of the Speech-Language Pathologist in the Recovery Process of Individuals with Traumatic Brain Injury

Jessica D. Richardson, Ph.D., CCC-SLP


Asha scope of practice

ASHA Scope of Practice

  • ASHA = American Speech-Language-Hearing Association

    • Scope of practice: http://www.asha.org/uploadedFiles/SP2007-00283.pdf


Role of the speech language pathologist in the recovery process of individuals with traumatic brain injury

Narrative Samples


Functional outcomes and reimbursement trends

Functional outcomes and reimbursement trends

  • Trend of reduced resources available for rehabilitation

  • Trend of increased demands for improved functional outcomes

    • Lessening activity/participation limitations is focus instead of traditional focus of eliminating/reducing the underlying impairment.

    • Treatment effectiveness is therefore demonstrated by meaningful improvements in the tasks of everyday life.

      www.asha.org/policy/


Functional outcomes and who icf

Functional outcomes and WHO-ICF

  • World Health Organization – International Classification of Functioning, Disability, and Health (WHO-ICF)

    • Classification system that describes disorders in terms of resultant limitations placed upon the individual

      • Limitations in body function and structure

      • Activity limitations

      • Participation limitations

      • Contextual factors


Who icf limitations in body structure function

WHO-ICF: Limitations in body structure/function

  • Previously known as “impairment”

  • Underlying damage to psychological, physiological, or anatomic structures or functions

    • e.g., inability to hold more than 6 items in memory, increased distractibility, word-finding deficits/anomia


Who icf activity limitations

WHO-ICF: Activity limitations

  • Previously known as “disability”

  • Functional consequences of the limitations of body function and structure

    • e.g., limitation of body structure and function = anomia/word-finding problem; resultant activity limitation = unable to add ideas or take turns in conversation

  • Predictive of participation limitations


Who icf participation limitations

WHO-ICF: Participation limitations

  • Previously known as “handicap”

  • Tied to one’s well-being and social consequences that arise from having cognitive disorder; discussed relative to life roles

    • e.g., Can the individual with a TBI still lead meetings, conduct class lessons, drive a truck (long-haul), etc.? If not, then participation in pre-TBI life activities is limited.


Who icf contextual factors

WHO-ICF: Contextual factors

  • Social, familial, educational, vocational, or other role disadvantage associated with the disability

    • e.g., failure in school, loss of job

  • Includes also:

    • Environmental factors

      • factors not within the person’s control (e.g., attitudes of individuals in the environment, family, work, government agencies, laws, cultural beliefs, etc.)

    • Personal factors

      • e.g., attitudes of individual with TBI, race, gender, age, educational level, coping styles, etc.


Flow of clinical services

Flow of clinical services

1 - Pre-assessment.

2 - The development of a clinical question regarding diagnosis, intervention, and/or discharge.

3 - Selection of assessment instruments.

4 - Assessment.

5 - Using the information to determine intervention approach.

6 - Intervention.

7 - Re-assessment.


1 pre assessment

1 - Pre-assessment

  • Thorough pre-assessment improves quality of assessment process and information gained

  • Especially important in TBI

    • history, substance abuse, depression, etc.

  • Sources of pre-assessment information can include:

    • Written case history

    • Interview with client and caregivers

      • Who is concerned about the client’s communication performance (client, other health professional, family member, etc.)? Why are they concerned?

    • Interview/Information from other professionals, Medical records


2 development of clinical question

2 - Development of clinical question

  • This is also Step 1 of evidence-based practice: “The development of a clinical question regarding diagnosis, intervention, and/or discharge.”

    • Does the person potentially have a disorder that falls under my scope of practice?

    • If yes, what domains seem to be affected?

    • What additional information do I need to obtain in order to have sufficient information for determining if the person actually hasone or more disorders?


3 selecting your assessment measures

3 – Selecting your assessment measures

  • Before using a standardized assessment measure, need to determine whether or not it is the appropriate measure to administer.

    • What is the purpose of the test?

    • How was the test constructed/developed?

    • What are the administration and scoring procedures?

    • What is the normative sample group?

    • Is this a valid test?

    • Is this a reliable test?

    • Which domain of WHO-ICF limitations does this test assess?

  • Will also need to use nonstandardized assessment measures


4 assessment 1

4 - Assessment (1)

  • Traditionally, assessment has involved:

    • Battery of tests of neuropsychological/cognitive/linguistic function to identify strengths and weaknesses (i.e., limitations of body structure/function)

  • Improved approach includes contextualized measures (aka “authentic” measures)

    • Arose because research has demonstrated that aforementioned assessment approach does a poor job assessing functional, real-world outcomes and/or long-term maintenance of treatment gains and does not assist with vocational planning

  • http://tbims.org/combi/list.html


4 assessment 2

4 - Assessment (2)

  • Standardized tests to identify deficits and to generate hypotheses about areas to target in rehabilitation

    • *comment on aphasia batteries for TBI

  • Situational observation

    • To confirm and enrich OR negate test findings

    • Why?


4 assessment 3

4 - Assessment (3)

  • Ongoing contextualized hypothesis testing

    • Systematic exploration of strategies, task modifications, supports, intervention procedures, etc. that could positively influence task performance and learning

    • Why ongoing and contextualized?

    • Why hypothesis testing?


4 assessment 4

4 - Assessment (4)

Measure the knowledge and support skills of the people in the everyday life of the person with TBI


4 assessment 5

4 - Assessment (5)

5. Collaboration with other professionals

  • Collaboration with the patient

    • Collaborating with the patient in the following is important for both assessment and treatment:

      • Goal-setting

      • Testing intervention hypotheses

      • Exploring strategic compensations

      • Monitoring outcomes

    • Evidence that direct patient involvement in neurorehabilitation goal setting => maintained goals at follow-up


Role of the speech language pathologist in the recovery process of individuals with traumatic brain injury

Big Picture

Rehabilitation Coordinator/Case Manager

Primary Physician

Neuropsychologist

Nurse

Psychologist

Patient

Medical

Consultants

Physical

Therapist

Occupational

Therapist

Social Worker

Recreation

Therapist

Speech

Pathologist

Vocational

Specialist

Nutritionist

Source: Christine C. O’Hara and Minnie Harrell, Rehabilitation with Brain Injury Survivors: An Empowerment Approach, Aspen Publishers, Inc., 1991.


4 assessment 6

4 - Assessment (6)

  • Why are all of these team members involved?

    • Primary Consequences

      • Penetrating Head Injury (Low-velocity, High-velocity)

      • Nonpenetrating (or closed) Head Injury (Nonacceleration, Acceleration [linear, angular])

        • Diffuse Axonal Injury

    • Some Secondary Consequences (brain’s responses to primary trauma, often more devastating than primary consequences)

      • Traumatic hemorrhage, cerebral edema, traumatic hydrocephalus, increased intracranial pressure, ischemic brain damage, cerebral vasospasm

    • Resultant Systemic complications

      • Skin, eye, ear, nose, mouth and throat, larynx, trachea, lungs, GI tract, heart, PVS, genitourinary system, female reproductive system, metabolic-endocrine system, blood, musculoskeletal system, PNS, CNS


4 assessment 7

4 - Assessment (7)

  • Assessment and Intervention Environments

    • Acute setting

    • Post-acute/sub-acute facilities

    • Day treatment/outpatient services

    • Group home/residential living

    • Vocational rehabilitation

    • Transitional living

    • Protected work trial

    • School

    • Private clinic

    • Behavior management

    • Pediatric programs

    • Brain injury + other conditions

    • Respite


4 assessment 8

4 – Assessment (8)

  • Assessment and Intervention will depend upon stage of recovery, e.g.,

    • STAGE 1 – “Comatose and Semi-Comatose”

    • STAGE 2 – “Responsive and Agitated”

    • STAGE 3 – “Restless and Distractible”

    • STAGE 4 – “Oriented, Purposeful”

    • STAGE 5 – “Dependent”

    • STAGE 6 – “Semi-Independent”

    • Also, Rancho Los Amigos Levels of Cognitive Functioning (p. 425)

      • http://www.rancho.org/research/cognitive_levels.pdf


5 determine intervention approach

5 - Determine Intervention Approach

  • Differential Diagnosis

  • Comorbid Diagnoses

  • Limitations and Contextual Factors

  • Hierarchy of Clinical Importance/Personal Importance

    • The “whole picture”

    • Prioritize immediate and less-immediate needs


6 intervention

6 – Intervention

To discuss


7 re assessment

7 - Re-assessment

Remember, assessment should be ongoing

Also, the final stage of evidence-based practice is to evaluate whether or not the chosen approach is working and to make modifications as necessary.


6 intervention1

6 – Intervention


Evidence based recommendations

EVIDENCE-BASED RECOMMENDATIONS

  • Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group (Cicerone et al., 2011, Arch Phys Med Rehabil)

    • ATTENTION

    • VISION and VISUOSPATIAL FUNCTIONING

    • LANGUAGE AND COMMUNICATION SKILLS

    • MEMORY

    • EXECUTIVE FUNCTIONING

    • COMPREHENSIVE-INTEGRATED NEUROPSYCHOLOGIC REHABILITATION


Evidence based recommendations1

EVIDENCE-BASED RECOMMENDATIONS

  • Practice Standards

    • At least 1 well-designed Class I study with adequate N

    • Additional support from Class II or Class III evidence

    • Directly addresses treatment effectiveness

    • Substantive evidence of effectiveness

  • Practice Guidelines

    • 1 or more Class I studies with methodologic limitations OR well-designed Class II studies with adequate N

    • Directly addresses treatment effectiveness

    • Evidence of probably effectiveness

  • Practice Options

    • Class II or Class III studies

    • Directly addresses treatment effectiveness

    • Evidence of possible effectiveness


Tbi and communication

TBI and COMMUNICATION


Tbi and communication 1

TBI and Communication (1)

  • Speech Impairment – a problem with voice, fluency, and/or how a person says speech sounds.

  • Language Impairment – a problem with understanding and/or using spoken, written, and/or other symbol systems.

    • Form – the rules about how sounds are combined, how words are constructed, and how we combine words to form sentences.

    • Content – the meanings of words.

    • Function – using language (form and content) to communicate in functional and socially appropriate ways.


Tbi and communication 2

TBI and Communication (2)

  • Low incidence of aphasia secondary to TBI

  • Communication problems secondary to TBI are quite different from aphasia, BUT aphasia assessment batteries are commonly administered

    • Problem with aphasia test batteries

    • "Performance on aphasia batteries may give the impression that their communicative skills are intact. However, interactions with many of the same individuals leave the listener with the sense that they are off target, tangential, and disorganized or, in some cases, have very little to say. The overestimated communicative performance of these individuals is a function of the limited scope and ceiling effect of aphasia batteries, which were never intended to assess the subtle types of deficits many individuals with TBI demonstrate.” Coelho et al., 2005, Seminars in Speech and Language

  • Impaired discourse is the hallmark of post-TBI cognitive-communication disorder


Tbi and communication 3

TBI and Communication (3)

  • Discourse abilities reside at crossroads of language and cognition

  • Anatomy:

    • Lateral and medial prefrontal cortices (LPFC, MPFC)

      • Dorsolateral LPFC

    • Temporoparietal and anterior temporal regions

    • Posterior cingulate

    • Connections between these areas, and from these areas to other lobes


Tbi and communication 4

TBI and Communication (4)

  • Discourse Impairment

    • Macro-linguistic deficits

      • Reduced cohesion and coherence; impaired organization; problems with story components and grammar

    • Difficulty with inference

      • Impaired social cognition

    • Reduced information and efficiency

      • Tangential language, difficulty identifying communication breakdowns and repairing

      • Shorter and less complex utterances

    • Reduced initiation and maintenance

      • Dependent on others to maintain flow of conversation

    • Micro-linguistic deficits

      • Meaning within words, phrases, sentences


Tbi and communication 41

TBI and Communication (4)

  • Discourse Impairment

    • Macro-linguistic deficits

      • Reduced cohesion and coherence; impaired organization; problems with story components and grammar

    • Difficulty with inference

      • Impaired social cognition

    • Reduced information and efficiency

      • Tangential language, difficulty identifying communication breakdowns and repairing

      • Shorter and less complex utterances

    • Reduced initiation and maintenance

      • Dependent on others to maintain flow of conversation

    • Micro-linguistic deficits

      • Meaning within words, phrases, sentences


Tbi and communication 42

TBI and Communication (4)

  • Discourse Impairment

    • Macro-linguistic deficits

      • Reduced cohesion and coherence; impaired organization; problems with story components and grammar

    • Difficulty with inference

      • Impaired social cognition

    • Reduced information and efficiency

      • Tangential language, difficulty identifying communication breakdowns and repairing

      • More turns of shorter and less complex utterances

    • Reduced initiation and maintenance

      • Dependent on others to maintain flow of conversation

    • Micro-linguistic deficits

      • Meaning within words, phrases, sentences


Tbi and communication 43

TBI and Communication (4)

  • Discourse Impairment

    • Macro-linguistic deficits

      • Reduced cohesion and coherence; impaired organization; problems with story components and grammar

    • Difficulty with inference

      • Impaired social cognition

    • Reduced information and efficiency

      • Tangential language, difficulty identifying communication breakdowns and repairing

      • Shorter and less complex utterances

    • Reduced initiation and maintenance

      • Dependent on others to maintain flow of conversation

    • Micro-linguistic deficits

      • Meaning within words, phrases, sentences


Tbi and communication 44

TBI and Communication (4)

  • Discourse Impairment

    • Macro-linguistic deficits

      • Reduced cohesion and coherence; impaired organization; problems with story components and grammar

    • Difficulty with inference

      • Impaired social cognition

    • Reduced information and efficiency

      • Tangential language, difficulty identifying communication breakdowns and repairing

      • Shorter and less complex utterances

    • Reduced initiation and maintenance

      • Dependent on others to maintain flow of conversation

    • Micro-linguistic deficits

      • Meaning within words, phrases, sentences


Tbi and communication 5

TBI and Communication (5)

  • EBRs

  • Practice Standards

    • Cognitive-linguistic therapy

      • Acute, postacute

    • Intervention to improve social communication skills

  • Practice Guidelines

    • Intervention for specific areas of deficit (e.g., reading, word-finding, narrative production)

    • Treatment intensity is a key factor

  • Practice Options

    • Group-based intervention for language and social-communication deficits

    • Computer-based interventions as an adjunct to clinician-guided treatment of cognitive-linguistic deficits


Tbi and communication 6

TBI and Communication (6)

  • Types of tasks

    • Social skills training

      • Pragmatic communication behaviors

        • Listening, starting a conversation

      • Social perception of emotions and social inferences

      • Psychotherapy for emotional adjustment

      • Self-instructional training strategies for emotion perception deficits (metacognitive strategies)

    • Narrative, conversation


Tbi and executive function

TBI and EXECUTIVE FUNCTION


What are executive functions

What are executive functions?

  • Executive functions = “superordinate, managerial capacity for directing more modular abilities, including language, memory, motor skills and perception in the service of managing and attaining goals” (p 487)

    • Maintenance of a problem-solving set for future goals (working memory)

    • Set shifting

    • Planning and problem solving

    • Decision making based on reward and penalty

    • Self-regulation


Frontal lobe functions 1

FRONTAL LOBE FUNCTIONS (1)

  • 4 Functional Domains

    • Executive

    • Behavioral/Emotional Self-regulatory

    • Energization regulating

    • Metacognitive


Frontal lobe functions 2

FRONTAL LOBE FUNCTIONS (2)

  • EFs mediated by frontally guided, distributed networks involving prefrontal subregions, posterior cortex, and subcorticalstructures (e.g., basal ganglia, ventral striatum)

  • 1 – Executive Cognitive Functions

    • Anatomy – lateral prefrontal cortex (LPFC)

    • Function Overview – control and direction of lower level/automatic functions

      • Planning, monitoring, activating, switching, inhibiting

  • 2 – Behavioral/emotional self-regulatory functions

    • Anatomy – ventral (medial) prefrontal cortex (VPFC)

    • Function Overview – emotional responsiveness, reward processing, behavioral self-regulation


Frontal lobe functions 3

FRONTAL LOBE FUNCTIONS (3)

  • 3 – Energization regulating functions

    • Anatomy – superior medial frontal lobes, anterior cingulate; frontal cortical-subcortical circuits

    • Function Overview – capacity to generate and maintain actions important for adequate performance of other functions

      • Extreme case – abulia, or severe apathy

      • Most common presentation – slowed reaction time, slowed processing speed

  • 4 – Metacognitive functions

    • Anatomy – frontal pole (BA 10) (right hemisphere bias?); connections to other regions

    • Function Overview – integrative aspects of personality, social cognition, consciousness, theory of mind, humor


Tbi and executive function1

TBI and Executive Function

  • TBI “arguably the most important single cause of frontal lobe dysfunction” (p 469)

  • The cognitive and behavioral consequences of TBI are the most enduring and have most impact (more than physical).

    • “The chronic disability of TBI is accentuated by its tendency to take place during early adulthood, affecting behavior for decades.” (p 469)

  • Can occur with both penetrating and non-penetrating TBI


Treatment of frontal lobe dysfunction 1

Treatment of Frontal Lobe Dysfunction (1)

  • 1 - Executive/cognitive

    • Problem solving and planning

      • Problem-solving training (PST)

    • Working memory training

  • 2 - Behavioral/Emotional Self-regulatory

    • Treatment targeting “goal neglect” (to bridge gap between intention and action)

    • Goal management training (GMT)

    • External aids/cues


Treatment of frontal lobe dysfunction 2

Treatment of Frontal Lobe Dysfunction (2)

  • 3 - Energization regulating

    • Pharmacologic intervention

      • Dopamine agonists, serotonin agonists

    • External aids/cues

  • 4 - Metacognitive

    • Deficit awareness

      • Awareness Intervention Program (AIP)

    • Error awareness and self-monitoring

      • Self-monitoring training (SMT)


Ebrs executive function 1

EBRs: EXECUTIVE FUNCTION (1)

  • Practice Standard

    • Metacognitive strategy training (self-monitoring, self-regulation) for executive functioning and emotional self-regulation

      • As a component of attention, neglect, and/or memory treatment

  • Practice Guideline

    • Problem-solving training (everyday situations, functional activities)

      • Postacute

  • Practice Options

    • Group-based intervention for executive function and problem-solving


Ebrs executive function 2

EBRs: EXECUTIVE FUNCTION (2)

  • Previous standards, guidelines, options were for adults only

  • There are no established cognitive interventions for children with TBI

    • Generally, approaches used for LD and ADHD are employed

  • Assessment and treatment of EFs in children is especially complicated, because of the diversity of EFs as well as the differences in developmental trajectories for the different EF processes

    • Gray and white matter volume, lateralization, and distribution of cognitive control changes with age; “notable shortage” of neuroimaging studies for ped TBI


Tbi and attention

TBI and ATTENTION


Attention 1

Attention (1)

  • Multidimensional

    • Sensory selective attentional system

      • Parieto-temporo-occipital area

      • Orienting, engaging, and disengaging attention and object recognition

    • Arousal, sustained attention and vigilance system

      • Midbrain reticular activating system and limbic structures

      • Arousal, sustained attention, vigilance, mood, motivation, salience of stimuli, readiness to respond

    • Anterior system for selection and control of responses

      • Frontal lobes, anterior cingulategyrus, basal ganglia, thalamus

      • Intentional control and use of strategies for manipulating information, active switching and inhibition


Attention 2

Attention (2)

Common terms and categorization in testing and treatment


Attention 3

Attention (3)

  • TBI => diffuse and bilateral injury to many regions including frontal, temporal, meso-limbic, and midbrain reticular formation areas

    • These areas are involved in attention

    • One of most common cognitive complaints post-TBI

    • Commonly assessed via:

      • Digit span (e.g., subtest of Wechsler Memory Scale; WMS)

      • WAIS - Digit symbol coding and symbol digit modalities tests

      • SART – Sustained Attention and Response Task

      • TMT – Trail Making Test

      • BTA – Brief Test of Attention

      • TEA – Test of Everyday Attention

      • Attention Questionnaire


Attention 4

Attention (4)

  • Sensory selective attentional system

    • Rarely damaged relative to other systems

    • If damaged, => object recognition difficulty, unilateral spatial neglect

  • Arousal, sustained attention and vigilance system

    • Commonly damaged

    • If damaged, => decreased perceptual sensitivity/decreased vigilance

  • Anterior system for selection and control of responses

    • Commonly damaged

    • If damaged, => slower to perform selective and divided attention tasks, impaired speed of information processing (increased RT), distractible,


Attention 5

Attention (5)

  • EBRs

  • Practice Standards

    • Remediation of attention during postacute rehabilitation

    • Should include direct attention training

      • Contextualized

    • Should include metacognitive training to promote development of compensatory strategies and foster generalization to real-world tasks.

  • Practice Option

    • Computer-based interventions as an adjunct to clinician-guided treatment of attention deficits


Tbi and memory

TBI and MEMORY


Memory 1

MEMORY (1)

  • Working (and short-term) memory - involved in the acquisition of new information and the activation of old or stored information whenever it is needed for a task; make contact with the knowledge in LTM

  • Long-term memory (LTM)

    • Retrospective memory – memory for past events and experiences and for information acquired in the past

      • Declarative memory

        • Episodic memory

        • Semantic memory

      • Procedural memory

    • Prospective memory – ability to remember to do things at specific points in time


Memory 2

MEMORY (2)

  • TBI => diffuse and bilateral injury to many regions including temporal and basal-frontal regions

    • These areas are involved in memory

    • Difficult to separate from attention

    • Commonly assessed via:

      • WMS - Wechsler Memory Scale

        • Digit/letter/word span for immediate retention

      • AMI – Autobiographical Memory Interview

      • GOAT – Galveston Orientation and Amnesia Test

      • RBMT – Rivermead Behavioral Memory Test

      • CAMPROMPT – Cambridge Prospective Memory Test

      • Corsi Block-tapping Test

      • Memory for Designs Test (of Stanford-Binet Intelligence Scale)


Memory 3

MEMORY (3)

  • EBRs

  • Practice Standard

    • Memory strategy training (internalized strategies [e.g., visual imagery], external memory compensations [e.g., notebooks])

      • Mild memory impairment

  • Practice Guideline

    • Memory strategy training (with external compensations) with direct application to functional activities

      • Severe memory impairment

  • Practice Options

    • Errorless learning for specific skills or knowledge

      • Severe memory impairment

      • Evidence of limited transfer/generalization

    • Group-based intervention


Treating the whole patient

TREATING THE WHOLE PATIENT


Ebrs comprehensive holistic neuropsychologic rehabilitation

EBRs: COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION

  • Practice Standard

    • C-HNR to reduce cognitive and functional disability

      • Postacute

      • Moderate to severe TBI

  • Practice Options

    • Integrated cognitive + interpersonal + comprehensive neuropsychological rehabilitation

    • Group-based interventions


Comprehensive holistic neuropsychologic rehabilitation 1

COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION (1)

  • Cicerone et al., 2004, 2008

  • Outpatient, postacute

  • Comprehensive-Holistic = 16 weeks (15-20 hours/week)

    • Core treatment

      • Individual and/or group psychotherapy, family support and involvement, therapeutic work trials, ADLs, assessment of progress, observing videotapes of communication/interaction, feedback to self and others, etc.

    • Cognitive group treatment

      • Functional activities with emphasis on executive functioning, metacognitive functioning, interpersonal group processes

    • Individual cognitive remediation (patient involved in goal setting and content of activities)

    • Group communication treatment – communication, interpersonal communication style, perspective taking, social behavior, pragmatic language skills

  • Standard = 16 weeks (12-24 hours/week)

    • Primarily individual, separate sessions of physical, occupational, speech, and neuropsychologic therapy

    • Also recreational, vocational, and/or educational therapy/intervention, psychologic counseling


Comprehensive holistic neuropsychologic rehabilitation 2

COMPREHENSIVE-HOLISTIC NEUROPSYCHOLOGIC REHABILITATION (2)

  • Comprehensive-Holistic => greater improvements when compared to standard neurorehabiltation program of similar intensity/duration

    • Twice the magnitude of treatment effects observed in community integration

    • Also => greater improvements in neuropsychologic functioning

    • Improvement on complex attention and executive functioning tasks directly related to community integration


Pediatric tbi and academic re entry

Pediatric TBI and Academic Re-entry


Community integration and vocational rehabilitation

Community Integration and Vocational Rehabilitation


Tbi and disorders of mood affect and motivation

TBI and disorders of mood, affect, and motivation


Tbi and psychosocial factors

TBI and psychosocial factors


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