A traumatic brain injury (TBI) is a type of cognitive communication disorder resulting from a physical trauma to the head or displacement of the brain (ASHA, 2018). TBIs are categorized as mild, moderate, or severe based on the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5). The origin of the injury, the amount of time the individual was unconscious, and the post-traumatic amnesia contribute to the classification of severity (ASHA, 2018). The symptoms vary dependent upon the site of the lesion and the amount of damage imposed upon the brain. While some TBI symptoms may be noticeable early on, others such as post-traumatic stress disorder, anxiety, sleeping difficulties, and depression may develop over time.
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A TBI can affect cognition such as memory, perception, and attention, which may lead to language deficits. Communication involves language, cognition and speech. There is no definitive evidence for an effective standardized treatment program to help memory dysfunction, and little research discussing long-term improvement for any treatment modality. However, research has consistently shown a larger effect size for memory improvement in TBI patients after clinical rehabilitation when compared to TBI patients who received no treatment (Elliott & Parente, 2014).Cognitive rehabilitation therapy is broad because of the unique nature of brain injuries. A few popular therapy techniques used to strengthen memory are external memory aids, internet based remediation, andvirtual reality therapy.
Treatment as per SLP
Traumatic brain injury intervention may focus on developing compensatory memory strategies, formal problem-solving strategies, their application to functional activities, and improving attention at various levels of complexity. Treatment targets may focus on improving the way different types of information are processed: verbal, non-verbal, and social cues (ASHA, 2018). Interventions for specific language impairments such as reading comprehension and language formation may also be addressed. Time is of the essence when competing with the short-lived, and weak, spontaneous regenerative mechanisms that are responsible for counteracting the progression of damage to the brain (Zanier, Zoerle, Lernia, & Riva, 2018). Treatment can provide important benefits even in the early stages of acute recovery by working towards the achievement of a general response to sensory stimulation (ASHA, 2015). Once the patient can better respond to stimuli, therapy is likely to target maintaining the individual’s attention for basic activities. Once attention is established, the next step of memory improvement may commence. Logging thoughts in a diary, learning problem solving strategies, and ways to improve organizational skills are just a few of the tools that may be used for memory strengthening. Finally, the therapist may take the patient out into the community, helping the individual carry out trips and events with a memory log, and following checklists or organizers. Kennedy et al. (2008) argued self-regulation plays a significant role in the intervention of memory after a TBI. Functional imaging studies show activation of specific areas of the frontal lobe during actives that call for use of working memory. Therefore, intervention to improve memory through self-regulation usually takes two general approaches. One approach focuses on memory while the other approach focuses on the assumption that individuals with TBI use internally generated feedback when making study strategy decisions. The second approach forces the individual to engage in step-by-step procedures with the goal being to use a strategy successfully in working towards improved self-regulation.
External Memory aids
Prospective memory is being able to remember how to carry out a certain event at a certain time. It is a vital component for activities of daily living. Bos, Babbage, & Leathem (2017) discussed the efficacy of memory aids for individuals who have suffered a TBI resulting in difficulties with prospective memory. External memory aids such as a memory notebook and electronic memory aids such as smart phones, have the ability to compensate for memory deficits without the added cognitive stress involved in executive functions. Bos et al. (2017) included 7 adult males who suffered a moderate to severe TBI at least 2 years prior to being recruited for the study. Participants were given either a custom designed memory notebook including sections for personal info, a calendar notes, and people, or a smart phone with Goggle account synching capabilities for email, calendar, etc. The Test of Memory Malingering, Rivermead Behavioural Memory Test, and functional memory tasks were used by the researchers to determine the efficacy of each memory treatment. The functional memory tasks included a message task requiring the participant to either call or text at a scheduled time regarding a specific question and an unscheduled task. The unscheduled task was returning a post card via the post before the start of their next weekly appointment. All participants attended a one hour-long weekly appointment through the main data-collecting period. Each appointment consisted of a semi-structured client interview ending with the participants being given their two functional memory tasks, followed by prompted to log the tasks into their memory aid if they did not initially do so on their own. Participants were trained to use both devices, instructions for the memory notebook were inside the notebook itself, and instructions for the smart phone were step-by-step screenshots provided on paper. Bos et al. (2017) demonstrated that a smart phone cab be used effectively as a prospective memory aid. Performance for assigned memory tasks mostly improved as seen by the increase in accuracy for the completion and relevance of the assigned time message task. The ability of being able to add reminders and notes to an electronic calendar was seemingly efficient in prospective memory performance. In contrast, the unscheduled post card task remained variable. Due to sample size, the memory notebook and smart phone could not be directly compared. Other limitations include the strictly male sample. Two months later, the majority of participants maintained their improved memory task performance. When applying Bos et al. (2017) results to current treatment for TBI, the clinician should keep in mind that therapy, including modern devices such as smart phones, may be more individual for younger as opposed to older adults. In addition, one may investigate which combination of cognitive and other factors promotes ease in learning to independently use a smart phone.
Research conducted by Bergquist et al. (2009) determined whether memory rehabilitation delivered via Internet can produce improvements in functioning just like face-to-face therapy. Sohlberg and Mateer described the calendar acquisition approach used in the study, which has consistently seen support for being used in improving functioning of daily life when used with numerous face-to-face therapy sessions (as cited in Bergquist et al., 2009). The downside is that special training is required for individuals wanting to deliver this kind of treatment. This leaves patients to commute long distances. With an increasing demand for the Internet, it would be beneficial for such therapies as well as others to be administered successfully online. The sample included 14 individuals who completed 30 sessions of active calendar acquisition intervention and 30 sessions of a control diary intervention. All 60 of the online sessions were conducted using instant messaging system online. All participants were trained on both the Calendar and Diary interventions and were randomly selected to use a single intervention first. The Neurobehavioral Functioning Inventory, Community Integration Questionnaire, and Compensation Techniques Questionnaire were administered during the baseline evaluation and after completing the 30 sessions of a single intervention type via instant messaging with a speech therapist online (Bergquist et al., 2009). Then, the participants completed 30 sessions of the alternate intervention, followed by a final assessment session. The calendar intervention taught the participant how to use a calendar system to compensate for their memory problems and develop strategies to improve memory functioning in identified aspects in order to improve day-to-day life. The Diary intervention was meant to be the control without cognitive rehabilitation. The Internet therapy sessions included reviewing the diary log of day-to-day events and occurrences since the last session. No differences were noted between the active and control condition. However, there were significant improvements in functioning in calendar use between baseline and final assessment. Family members rated participants as having a better mood on the NFI at the end of the intervention. Even though the control did not represent formal therapy, it still facilitated the planning of a scheduled future event and recall of recent past events (Bergquist et al., 2009). Because of this, the control may still have had a therapeutic effect. Over all, it was found that performance had improved after all 60 Internet sessions and showed an increase in compensatory strategies used in everyday life. Self-ratings of memory and mood on the NFI did not change, but this could be due to the impairment in judgment caused by a TBI (Bergquist et al., 2009). The results provided evidence that cognitive rehabilitation may in fact be helpful for certain individuals. It offers direction for further research in how severity of impairment post brain injury may play a role in the effectiveness of the current therapy.
Banville and Nolin (2012) used virtual reality to test the ability to memorize an intention and the action(s) to carry it out with executive function acts such as action planning, monitoring the environment, and activation/ inhabitation of behaviors depending on the intention. Prospective memory for 31 post TBI patients was compared to 31 control participants on three prospective tasks with a visit to two virtual apartments. Participants were given the traditional prospective-memory assessment, The Rivermead Behavioral Memory Test, to determine inclusion. The virtual reality scenario briefed the participant that they would be moving to anew apartment in a new city. Each participant was told to visit both a small and a large apartment. Then, choose which one to live in based on personal needs and tastes amongst completing three specific prospective memory tasks. Each participant earned a prospective memory score for how his or her tasks were completed. Results showed that the participants with TBI were significantly less precise and took more time performing the prospective memory tasks in virtual reality compared to the control participants (Banville & Nolin, 2012). There is often a delay in treatment for TBIs until after discharge from the intensive care unit. Neuro-restorative responses take place during this time frame. Virtual reality allows engagement and cognitive involvement higher than what is provided by memory and imagination and is measured more easily than a direct experience (Zanier et al., (2018). Therefore, virtual reality interventions aimed specifically towards memory improvement can be helpful in decreasing long-term difficulties and disabilities in cognition and behavior for individuals who have suffered a TBI.
Memory, attention, and executive function are important pieces of our every day lives. All involve cognition, which plays a role in our constant cycle of processing language to formulate speech. Individuals who have undergone a TBI struggle with some or all of these areas depending on their etiology. For this reason, interventions may target all of these areas or may be specific to an area such as memory. It is believed the ability to remember to carry out important every day life activities is important in reflecting the independence an individual will have after a TBI (Banville & Nolin, 2012). Regardless, targets focus on being functional whether through a set of skills, realistic goals, establishing priorities, time frames, problem solving, or carrying out steps for executive functioning based on earlier ones. Changes in memory are more likely to be observed at the level of participation in activities of daily living than on standardized tests (Kennedy et al., 2008). Therefore, further advancements in virtual reality therapy will likely prove to be a beneficial tool as a stand-alone method or in combination with other treatments such as online therapy and external memory aids.
- American Speech-Language and Hearing Association. (2018). Practice portal. Retrieved from https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935337&sec tion=Treatment#Treatment_Options.
- American Speech-Language and Hearing Association. (2015). Speech-language pathology medical review guidelines. Retrieved from https://www.asha.org/uploadedfiles/slp-medical- review-guidelines.pdf.
- Banville, F., & Nolin, P. (2012). Using virtual reality to assess prospective memory and executive functions after traumatic brain injury. Journal of Cyber Therapy & Rehabilitation, 5(1), 45-55. http://link.galegroup.com/ezproxylocal.library.nova.edu/apps/doc/A321462389/AONE?u=novaseu_main&sid=AONE&xid=008e7de5. Accessed 24 Oct. 2018.
- Bergquist, T., Gehl, C., Mandrekar, J., Lepore, S., Hanna, S., Osten A., & Beaulieu, W. (2009). The effect of internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Injury, 23(10), 790-799. DOI: 10.1080/02699050903196688
- Bos, H. R., Babbage, D.R., & Leathem, J. M. (2017). Efficacy of memory aids after traumatic brain injury: A single case series. NeuroRehabilitation, 41, 463-481. DOI:10.3233/NRE-151528
- Elliot, M., & Parente F. (2014). Efficacy of memory rehabilitation therapy: A meta- analysis of TBI and stroke cognitive rehabilitation literature. Brain Injury, 28(12), 1610-1616. DOI: 10.3109/02699052.2014.934921
- Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker, M., Sohlberg, M.M., Yorkston, K.,…Kan P.F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation 18(3), 257-299. DOI:10.1080/09602010701748644
- Pala, P.A., N’Kaoua, B., Mazaux, J.M., Simion, A., Lozes, S., Sorita, E., & Sauzeon, H. (2014). Everyday-like memory and its cognitive correlates in healthy older adults and in young patients with traumatic brain injury: A pilot study based on virtual reality. Disability and Rehabilitation: Assistive Technology, 9(6), 463-473. DOI: 10.3109/17483107.2014.941952
- Zanier, E.R., Zoerle, T., Lernia, D.D., & Riva, G. (2018). Virtual reality for traumatic brain injury. Frontiers in Neurology, 9, 1-4. DOI: 10.3389/fneur.2018.00345
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