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Welcome to this SpeechPathology.com Live Expert e-Seminar! Mild Traumatic Brain Injury Update Presented By:
Gail V. Pashek, Ph.D., CCC-SLP, Speech-Language Pathologist, Kansas City Veterans Administration Medical Center Moderated By:
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Mild Traumatic Brain Injury(mTBI): An Update Gail V. Pashek, Ph. D., CCC-SLP Kansas City Veterans Administration Medical Center, Kansas City, MO
[email protected]
The opinions expressed in this presentation and products endorsed reflect the views of the author alone and not the official policy of the Veterans Health Administration, Department of Defense, or U.S. Government.
Disclaimer Pashek, 2010
“Mild Traumatic Brain Injury” ◦ VA Guidelines – closely follow those provided by ◦ American Congress of Rehabilitation Medicine (1993) one or more of the following: LOC <5 min Any loss of memory for events before or after accident Any alteration in mental state – up to 24h ◦ Dazed ◦ Confused ◦ PTA
Focal neurological deficits Exclusion criteria: ◦ LOC > 30 min. ◦ PTA >24 h ◦ Initial GCS less than 13
Definition Pashek, 2010
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CDC Statistics 1.4 million incidence/5.3 million prevalence 75% considered “mild” McKinlay et al. 2008 1 in 5 children will sustain a brain injury before age 16 of which 90% are judged to be “mild” U. S. Government 50% of all war-related injuries – TBI 23% of all returning soldiers 80% “mild
Incidence of TBI/mild TBI Pashek, 2010
Life disruption is not necessarily proportional to the “mildness” of injury as judged by a medical evaluation Doesn’t mean effects will be less dire on pt or family Pt’s awareness of problem often creates greater frustration than in more severe TBI “I don’t look any different, but I know I’m different.” People don’t understand.” Percussion effects of multiple blasts on the brain
“Mild” Traumatic Brain Injury Pashek, 2010
Blast Injury Changing the Face of Mild Traumatic Brain Injury
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Blast Injury (Explosive Blast Neurotrauma) Wallace, 2008 Pashek, 2010
Increased incidence of TBI and mTBI in the Iraq and Afghanistan wars relative to previous wars ◦ 80% of all war-related injuries are blast-related ◦ 40-50% involve traumatic brain injury ◦ High order explosives
Susceptibility of military roles Increase in survival - improved protective equipment (body armor, Kevlar helmet)
Blast Injury in the Military Pashek, 2010
U. S. Department of Defense (DOD) and Veterans Administration (VA) •
Population-wide screening for mTBI/concussion in the military • Upon return from deployment, • 3 to 6 months • Upon entering the VA for care
Query: Did you experience a blast or explosion, vehicle accident, bullet wound, fall, or other injury event with: • • • •
Loss or alteration in consciousness? Headache, difficulty sleeping, anxiety, Number of incidents? At what distance?
Blast Injury in the Military - 2 Pashek, 2010
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Civilians are at risk during war, both children and adults Terrorism is increasingly affecting civilians ◦ 2000-2003 70 suicide bombing attacks – Israel (Weil et al., 2007), ◦ Oklahoma City – Murrah Building 1995 ◦ Madrid train bombings 2004 ◦ London bus bombings 2005
Other accidents involving explosions (e.g., gas leaks, fireworks accidents, etc.) Children more likely to develop head injuries than adults or adolescents
Civilian Casualties Pashek, 2010
Direct Injuries – 4 levels defined ◦ Primary (positive and negative blast wave) ◦ Secondary (projectiles hitting the body) ◦ Tertiary (the body as projectile) Quaternary (burns, crush injuries, injuries from toxic fumes)
Indirect Injuries
Blast Injuries Pashek, 2010
Primary Blast: Atmospheric overpressure followed by under-pressure or vacuum; 1,000 mph ◦ Skull displacement causing tension and pressure in the brain ◦ Contusions ◦ Diffuse Axonal Injury (DAI)
Primary Blast Injury Pashek, 2010
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Contusions
Coup/Contrecoup
Localized damage also occurs when the brain bounces against the skull. The brain stem, frontal lobe, and temporal lobes are particularly vulnerable to this because of their location near bony protrusions inside the skull.
Primary Blast Injury Pashek, 2010
Vulnerable Areas
Axonal Injuries
◦ Diffuse axonal injury (DAI) –hippocampus, amygdala, brain stem) ◦ Transfer of kinetic energy from blast wave to brain, causes DAI ◦ Cernak et al. - blast injury effects on rats swellings of neurons, glial reaction, and myelin debris in the hippocampus Performance deficits within 3h
Primary Blast Injury Pashek, 2010
DAI Prone Areas Pashek, 2010
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Secondary Blast Effects Objects placed in motion by the blast hitting the service member Greatest risk of penetrating-head injury Shrapnel wounds
Secondary Blast Effects Pashek, 2010
Tertiary Blast Effects
Injury sustained when the body is placed in motion by the blast Contusions – coup and contrecoup injuries DAI
Tertiary Blast Effects Pashek, 2010
Blast Injury & Polytrauma
◦ Overblast effects on organs feeding the brain ◦ Demonstrated hypoxia in myocardial depression without a compensatory vasoconstriction in research animals (Irwin et al., 1997) Schematic – U. S. Army Medical Department
Blast Injury – Indirect Effects on the Brain Pashek, 2010
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High pressures lead to air-filled organ failure High frequency of vasospasms – early and late (Ling, Bandak, Armonda, Grant & Ecklund, 2009) Risk of pseudoaneurysm Multiple blasts - decreased threshold of internal organ injury (Yang et al. 1996)
Blast Injury - Polytrauma Pashek, 2010
Blast injury/sports injury – both have risk of repetitive injury ◦ Sports – concern for Second Impact Syndrome ◦ Military following of concussion guidelines? A complex issue
Cognitive effects of multiple concussions – memory and attention (Moser, 2005; Guskiewicz, 2005 et al.) Yet, blast injury is more complex than sports concussion, given the over-pressure and underpressure atmospheric dynamics and the quaternary collateral trauma.
Blast Injury vs. Other TBI Etiology Pashek, 2010
Search continues for reliable biomarkers Present documentation is only self-report Criteria for removing soldiers from the field? Repetitive (percussive) injuries common There is little post-injury monitoring after a MTBI ◦ Limitations of self-report
Many Issues Remain Re Military Blast--related TBIs Blast Pashek, 2010
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“If you're talking about white, or even gray matter damage, it's often accompanied by loss of cognitive insight. If we're releasing these soldiers to the field with instructions to report any changes in their mental state, it probably won't happen because the person who suffers a mild brain injury is the least able to observe it in themselves. If a platoon leader sees them as filling a necessary niche and they appear to be doing well, they are not going to encourage them to report symptoms, either.” (Graf man, as Cited in Samson, 2007)
Military BlastBlast-Related TBI Pashek, 2010
Post-Concussive Syndrome
Most individuals with mild TBI recover fairly well within 3-6 months post-injury 10-30% - chronic post-concussive symptoms. Three categories of residual symptoms: ◦ Somatic (headache, tinnitus, sleep disorders etc.) ◦ Cognitive(memory, attention and concentration difficulties ◦ Emotional/Behavioral(irritability, depression, anxiety, behavioral disorders) and at risk for other psychiatric disorders including: Depression Vulnerability to post-traumatic stress disorder (PTSD)
Complicating Factors in the Study and Treatment of Blast or Other mTBI - PCS Pashek, 2010
DSM-IV 309.81 Post Traumatic Stress Disorder PTSD Definition/Criteria: A. (1) The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity. (2) The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
Complicating Factors in the Study and Treatment of Blast or Other mTBI - PTSD Pashek, 2010
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Additional DSM-IV criteria for PTSD B. The traumatic event is persistently reexperienced. C. There is avoidance of stimuli associated with the trauma and numbing of general responsiveness. D. There are persistent symptoms of increased arousal E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Complicating Factors in the Study and Treatment of Blast or Other mTBI – PTSD Pashek, 2010
Additional Factors Affecting Cognition
Potential Confounds of Alcohol and Substance Abuse Potential Confounds of Secondary Gain/Level of Effort Sleep Disorders Chronic Pain
Complicating Factors in the Study and Treatment of Blast or Other mTBI – PTSD Pashek, 2010
mTBI with Post Concussive Syndrome (PCS) mTBI without PCS mTBI with Post Traumatic Stress Disorder (PTSD) mTBI without PTSD mTBI with both PCS and PTSD PTSD without mTBI
Possible Presenting Disorders Pashek, 2010
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It has been argued that PTSD cannot occur in amnestic patients, those with LOC or other severe BI symptoms (Mayou, Bryant, & Duthie) ◦ Amnestic disturbance may not be complete, as described by King – “islands” of memory
Levi et al. (1999) actually found higher rates of PTSD symptoms in children with severe TBI than in children with moderate TBI or orthopedic injuries Combat related PTSD can surface and remain many years post-trauma Autobiographical memory training may not be beneficial to individuals with PTSD
PTSD in TBI: Controversies Pashek, 2010
There is no “front” to the war as in previous conflicts Flashbacks Nightmares Hypervigilance Dissociation Persistence of symptoms for long periods of time
Combat--Related PTSD Combat Pashek, 2010
Neuroimaging Developments in mTBI (Image Source: bic.missouri.edu/images/whitemattertracking.jpg) Pashek, 2010
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Common CT and MRI Structural Brain Images – no evidence of damage
When neuroimaging findings are present –outcome is “complicated mild TBI” - outcome more similar to moderate TBI Pathophysiology in blast injury as well as other etiologies of mTBI ◦ Injured cells exposed to extreme changes in intracellular/ extracellular chemical environments ◦ Disequilibrium – cells are susceptible to changes in blood pressure, flow characteristics ◦ Cytotoxic edema develops ◦ Estimated duration > 2 weeks ◦ Not evident in gross structural analysis
Traditional Neuroimaging Methods and the Pathophysiology of mTBI Pashek, 2010
DAI affects primarily white matter of the brain Diffusion Tensor Imaging (DTI)
DTI (Source: Wikipedia Commons)
◦ Sensitive to white matter changes in the exchange of intracellular and extracellular water diffusion in brain tissue ◦ Allows visualization of orientation and direction of white matter fiber tracts
Diffusion Tensor Imaging Pashek, 2010
Diffusion Tensor Image ◦ Diffusion MRI image Results from the statistical integration of displacement distribution of water molecules at a microscopic level with resolution in millimeters
Diffusion Tensor Imaging - 2 Pashek, 2010
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DTI Differential Diagnostic Potential 22 patients with semi-acute mTBI (x = 12 days po) 21 healthy matched controls with 3-5 mos. Po follow-up DTI differentially distinguished between normal brains and brains of individuals with TBI Detect changes both early and late post-injury (Mayer et al., 2010) However, the researchers also noted some normalization of white matter changes 3-5 mos. post initial imaging (Mayer et al. 2010)
Diffusion Tensor Imaging (Mayer, 2010) Pashek, 2010
Summary ◦ DTI Appears to be better diagnostic indicator of mTBI than CT or common structural MRI ◦ Global white matter pathology as determined by DTI negatively related to cognitive impairment in all cognitive domains (Kraus et al.) ◦ DTI changes noted over time may make it a neurological marker of mTBI recovery than clinical imaging with MRI or CT ◦ More longitudinal studies needed (e.g., problem of Dx in military)
Summary - Neuroimaging Pashek, 2010
Other neuroimaging methods being explored demonstrating potential: Magnetic Resonance Susceptibility Weighted Imaging (MR-SWI) ◦ “susceptibility” – degree of magnetization of a material in a magnetic field ◦ good at detecting “microbleeds” (<5mm) common in DAI– venous blood and iron storage
Magnetic Resonance Spectroscopy – allows non-invasive biochemical analysis of brain tissue for specific compounds (e.g., Nacetylaspartate, glutamate)
Neuroimaging - mTBI Pashek, 2010
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◦ Can mTBI and PTSD be distinguished on the basis of neuroimaging results? ◦ Can neuroimaging predict who will develop post-concussive syndrome?
Issues in Neuroimaging of mTBI/Blast Injury Pashek, 2010
Neurobehavioral Assessment of Mild Traumatic Brain Injury Pashek, 2010
Forms of Neurobehavioral Assessments 1. Neuropsychological 2. Cognitive Rehabilitation
Necessary Complementary
Forms of Neurobehavioral Assessments Pashek, 2010
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Neuropsychologic Evaluation ◦ Documents deficits; used for forensic/legal purposes ◦ “Static” snapshots of functioning (Parente, 2003) ◦ Focused on “product” of performance ◦ Loosely correlated to brain structure ◦ Assesses constructs of “intelligence” and psychopathology ◦ More didactic, diagnostic ◦ Projects functional abilities – construct validity
Cognitive Rehabilitation Evaluation
Focuses on retained abilities as well as deficits Dynamic picture of functioning Focused on “process” of performance Focus on learning potential and characteristics More pragmatic, prognostic Assesses functional abilities in meaningful contexts – ecological validity
Two Forms of Evaluation Pashek, 2010
Prototypical mTBI patient seen in our clinic ◦ ◦ ◦ ◦ ◦
Exposure - multiple blasts Often no LOC - dazed or disoriented Good verbal skills in interview Memory, concentration complaints PCS symptoms – headache, insomnia, tinnitus, irritable, depressed ◦ PTSD – hypervigilant, isolationist, possibly fearful, non-emotive ◦ Generally, very aware of deficits
Military mTBI Patient Pashek, 2010
Chart review – emphasizing psychiatric, psychological, educational, and vocational notes Medication review Structured Interview – with pt and other who knows the pt well; key components: Cognitive Questionnaires Brief Technology Questionnaire (e.g., Gillette,
Direct Testing
DePompei & Goetz, 2009)P
Components of a ProblemProblem-Focused Cognitive Rehabilitation Evaluation Pashek, 2010
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ANCDS Practice Guidelines for Assessment available at www.ANCDS.org 1) Turkstra, L., Ylvisaker, M., Coelho, C., Kennedy, M., Sohlberg, M. M., & Avery, J. (2005). Practice guidelines for standardized assessment for persons with traumatic brain injury. Journal of Medical Speech-Language Pathology, 13(2). Detailed psychometric analyses of and expert commentary on measures commonly administered by speech-language pathologists. also, 2) Coelho, C., Ylvisaker, M., & Turkstra, L. (2005). Nonstandardized assessment approaches for individuals with traumatic brain injuries. Seminars in Speech & Language. 26(4):223-41
Pashek, 2010
Traditional SLP-oriented TBI measures are usually insufficient to pick up deficits described by mTBI patients: Brief Test of Head Injury (BTHI; Helm-Estabrooks, 1991) Scales of Cognitive Ability for Traumatic Head Injury (SCATBI; Adamovich & Henderson, 1992) Cognitive Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001)
Burns Brief Inventory of Communication and Cognition (Burns, 1997) Ross Information Processing Assessment (RIPA-2;
Ross-Swain, 1996)
Selection of Formal Measures Pashek, 2010
◦ ◦ ◦ ◦
Goals of patient, AND significant other Self-described problems Questionnaires – skills in context “Systems” Review
Perception Speech Language Attention Memory – recent, remote, event, prospective Executive Functions Speed of Processing
◦ Plus questions regarding: Learning Style Sleep “Average” day
Semi-structured Cognitive SemiCognitive--Plus Interview Pashek, 2010
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Highlighted Measures Especially suitable for MTBI Pashek, 2010
Standardized Questionnaire – administered both to patient and significant other ◦ Frontal Systems Behavioral Scale
(FrSBe; Grace
& Malloy, 2001 ) – 3 areas of frontal lobe functioning “Apathy” “Disinhibition” “Executive Functions”
◦ Pre- and Post-injury (deployment) ratings ◦ Observe how patient completes the measures
Evaluation Measures Pashek, 2010
◦ Memory ◦ California Verbal Learning Test (CVLT-II; Delis, Kramer, Kaplan & Ober, ) – verbal list learning ◦ Improvement over repeated trials ◦ Recall vs. recognition memory ◦ Organization recall characteristics Role of interference – proactive, retroactive
◦ Delayed memory
◦ Copy, immediate recall, and delayed recall of the Rey-Osterrith Complex Figure Perceptual/constructional ability Visual memory
Measure Selection and Analysis: Author’s Preferred Measures Pashek, 2010
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Executive Functions/Everyday Problem Solving Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; McDonald, 2005)
“standardized test of subtle cognitive-communicative difficulties designed specifically for those with acquired brain injuries…[and which] is designed to detect deficits which may not be apparent on typical standardized tasks” (p. 1) Targeted skills – complex comprehension/expression, verbal reasoning, executive functions Author notes that a number of deficits may not become apparent until the cognitive load reflects the complexities of daily living situations Ecological validity
Measure Selection and Analysis Pashek, 2010
A. FAVRES 4 tasks 1. Scheduling an event 2. Scheduling 3. Making a decision 4. Building a case Can administer and interpret individual tasks, although analysis across tasks is recommended
Measure Selection and Analysis Pashek, 2010
FAVRES Scoring System Points
Basis of Score 5
Answer choice accounts for all facts mentioned in question
4
Answer choice accounts for more than half of the facts in the question
3
Answer choice accounts for more than half of the facts in the question
2
Answer choice accounts for less than half of the facts in the question
1
Answer choice reflects an inaccurate attempt to consider one fact
0
Answer choice is entirely inaccurate, inappropriate, or no answer given
Measure Selection and Analysis Pashek, 2010
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Interpreting Scores Within and Across Tasks 1. 2. 3. 4.
Normal Cut Off scores Accuracy and Rationale Percentiles/SS Time Percentiles/SS Reasoning Subskills a. b. c. d. e. f. g.
Getting the facts Eliminating irrelevant information Weighing facts Flexibility Generating alternatives Predicting consequences Total reasoning subskills
FAVRES Summary Skills Pashek, 2010
Commentary: Repeatable Battery of Neuropsychological Status (RBANS)
Commonly used by neuropsychologists and now speech-language pathologists Good psychometric properties However, the RBANs is a screening tool that is oriented more toward documentation of an impairment than a therapy evaluation ◦ Does not allow for analysis of strategies as other tests (e.g., CVLT) do, e.g., organizational strategies in list learning ◦ Language portion is generally too easy to pick up subtle deficits or strategies ◦ Measures of attention (digit span, symbol digit task) do not get at higher level attention disorders, such as divided attention, distractibility
Repeatable Battery of Neuropsychological Status Pashek, 2010
Anecdotal/Surprising Findings in Assessment of Blast Injury Patients with Blast Injury/Mild TBI by This Author ◦ Extremely mild, often subclinical deficits ◦ Cognitive deficits apparent in testing in PTSD only cases ◦ Autobiographical memory/remote memory loss without retrograde amnesia in some individuals (if PTSD, working on autobiographical memory may not be recommended) ◦ Slowing of cognitive performance, in some instances comparable to that in older adults ◦ Varied divided attention deficits; vigilance often is quite good
Blast Injury Assessment Profiles Pashek, 2010
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Cognitive Rehabilitation Treatment: Mild TBI Focus on Executive Functions Pashek, 2010
“Cognitive/language (or cognitive rehabilitation) evaluation and treat as indicated”
Request for Referral Pashek, 2010
Approaches to mTBI adults Greatest face validity and strongest efficacy data Pashek, 2010
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Restoration vs. Compensation A Useful Controversy? Pashek, 2010
Restorative Approach Perspective ◦ Restorative Treatments (Coltheart – “Cognitivist Approach”– Based on model of the cognitive process and deficit and of neurological recovery mechanisms ◦ Focus on “experience driven plasticity” ◦ Cognitivists argue that compensatory approaches are atheoretical ◦ Approaches assume that teaching compensatory strategies may negatively affect potential for restoration of function (largely based on results of selected animal studies) The jury is still out…
“Restorative” Approach Pashek, 2010
Cognitive Prostheses ◦ ◦ ◦ ◦
PDAs Memory Books Recorders Medication Organizers
Environmental Compensation ◦ Family prompts ◦ Labeling of the environment, etc.
Internal Strategies ◦ Word Substitution ◦ Asking for help, etc.
“Compensatory” Approaches Pashek, 2010
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Some “compensatory” approaches appear have some degree of restorative potential in some individuals, e.g.: ◦ ◦ ◦ ◦
Circumlocution Use of imagery Self-talk to organize action “Re-organization Approaches e.g., “Gestural facilitation of speech,” “Treatment of Aphasic Perseveration” etc.
Can Some “Compensatory” Strategies Facilitate Restoration? Pashek, 2010
Compensatory Approaches Pragmatically driven ◦ ◦ ◦ ◦
Rehabilitation Funding Early success Functional need Lack of strong neuropsychological models for many cognitive processes/deficits ◦ Lack of evidence of detrimental effects in humans ◦ Fairly strong evidence base for some interventions
Compensatory Approaches are Necessary Pashek, 2010
Use of Cognitive Prosthesis – External Aids An Expanding Field Pashek, 2010
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ANCDS Practice Guidelines for Treatment available at www.ANCDS.org Sohlberg, M. M., Kennedy, M. R. T., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence based practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech Pathology, 15 (1).
Cognitive Prostheses – Meeting Immediate Functional Needs Pashek, 2010
General Cognitive Aids Medication organizers with/without alarms Alarm watches Smartphones, PDAs and written planners ◦ Appointments, medications, memos ◦ Customizable applications (e.g., bank reminder for bill paying) our goal is to have the client “glue” their PDA to them
Devices with GPS capability ◦ Topographical orientation disorder ◦ Also useful for attention deficits in drivers
Cognitive Prostheses – Meeting Immediate Functional Needs Pashek, 2010
Academic cognitive aids ◦ Digital recorders ◦ “Smart” pens ◦ Cognitive prostheses to aid with time management
Consideration: The devices themselves are not the therapy; training appropriate and expansive use of these aids IS
Cognitive Prostheses – Meeting Immediate Functional Needs Pashek, 2010
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Training Executive Functions, Memory, and Attention – Facilitating Organized, Goal Directed Thinking and Strategies Pashek, 2010
Treatment of Executive Functions - Self Management and Regulation “Converging evidence from educational, cognitive, and neuropsychological rehabilitation indicates that self-regulation is represented as the dynamic relationships among metacognitive beliefs and knowledge, self-monitoring and self-control during activities, and strategy use.” (p. 252)
Kennedy et al., 2005 Pashek, 2010
Focus on Self Management and Self Regulation
Goal Setting and Goal Management Problem Solving Awareness and Metacognitive Strategy Training
Treatment of Executive Functions Pashek, 2010
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Strong ecological validity Necessarily involve patient in treatment process Particularly well-suited to individuals at transitional points in life Based on self-regulation theory (see
McPherson et al., 2009) Several approaches to be discussed:
◦ Goal Setting Guide (Pashek, unpublished) ◦ Identity Oriented Goal Training (Ylvisaker & Feeney, 2000) ◦ Goal Management Training (Levine & Robertson, 2000)
Goal Oriented Therapies Pashek, 2010
ANCDS Practice Guidelines for Treatment available at www.ANCDS.org Kennedy, M. R. T. & Coelho, C. (2005). Self-regulation after traumatic brain injury: A framework for intervention of memory and problem solving. Seminars in Speech and Language, 26, 242-255. Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker, M., Sohlberg, M. M., Yorkston, K., Chiou, H. H. & Kan, P. F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, metaanalysis and clinical recommendations. Neuropsychological Rehabilitation, 18 (3), 257-299 .
Treatment of Executive Functions Pashek, 2010
Goal Development Treatments Pashek, 2010
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Goal Setting Guide ◦ Identify a Goal (graphic organizer) Provide Aids (if needed) What goals have you achieved in the past? Why were they important? Identify potential areas – (personal, work, spiritual, recreational, etc.) What is important to you now?
◦ What steps do you need to do to achieve this goal? ◦ What might get in the way of achieving this goal?
Initial Goal Setting Guide: Sample 1 (Pashek, unpublished) Pashek, 2010
Identity Oriented Goal Training (IODT) Six-step questioning process: Who is someone you admire? Identify characteristics of the person? What characteristics do they have? (facts, appearance) What goals did s/he have? Identify goal and feeling achieving the goal would give.
Initial Goal Setting Guide: Sample 2 (Ylvisaker et al., 2009) Pashek, 2010
Goal Management Training (Levine & Robertson, 2000) Best researched method Focused on decreasing the possibility of failure STOP DEFINE LIST LEARN TEST DO IT CHECK
What am I doing? The main task The steps The steps Do I know the steps? Am I doing what I planned)
Identity Oriented Goal Training Pashek, 2010
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Goal 1
Goal 2
Goal 3
Review Date Much more than expected (+2) More than expected (+1) As expected (0) Less than expected (-1) Much less than expected (-2)
Goal Attainment Scaling (GAS) A Method for Quantifying Progress Pashek, 2010
Self-management strategies recommended in attention and memory training as well from evidence-based reviews using a variety of treatment approaches Attention - Sohlberg, Avery, Kennedy et al. (2003). Memory - Erlhardt, Sohlberg, Kennedy et al. (2008).
Pashek, 2010
Is patient driven, to the extent possible Attaches a measure to often difficult-toquantify goals Promotes organized thinking and metacognitive skills Accommodates multiple rehabilitation goals in one measure Provides focus to treatment and for patients with attention/memory problems Assists in overall treatment management, discharge planning Is potentially generalizable (McPherson, Kayes, & Weatherall, 2009)
Advantages to GAS Pashek, 2010
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Especially helpful in assisting young service members who ◦ Understood the concept of goal (“mission”) in the context of their service ◦ Must totally revise goals with medical discharge ◦ Were never particularly goal-oriented to begin with ◦ Are at a point in life when goal-setting becomes particularly important
Goal setting for Military Patients Pashek, 2010
Meta-analyses tell us what works and how well it works There remains a need to know WHY such strategies are effective Speculation: ◦ Critical role of central executive in all activities? ◦ Training of a generalized organized thinking process? ◦ Strength of multimodal training? ◦ “Top-down” strategy, rather than incremental bottom-up? ◦ Real life, functional significance for client? ◦ Increasing self-awareness?
The Need to Know Why… Pashek, 2010
Does cognition in mTBI vary as a function of etiology? How much overlap is there between mTBI and PTSD in cognitive impairments? Are pharmaceutical agents effective in remediation of cognition in mTBI and PTSD? How can virtual reality be employed in cognitive rehabilitation?
Future Directions/Needs Pashek, 2010
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