Treatment of Mild Traumatic Brain Injury

Editor’s Note: This text is a transcript of the course, Treatment of Mild Traumatic Brain Injury, presented by Erin Mattingly, MA, CCC-SLP, CBIS.

Learning Outcomes

After this course, participants will be able to:

1. Identify common symptoms of mild traumatic brain injury and treatment ideas for each.
2. Describe how to engage patients in goal setting, treatment planning, and treatment follow-through.
3. Describe the unique requirements of returning to school and returning to work.

Thanks so much for joining today. I'm looking forward to Part 2 of our two-part series focusing on mild traumatic brain injury. Part 1 (Course 9756)  covered evaluation of mild traumatic brain injury and in this course, I will be talking more about the treatment aspect of mTBI.

Agenda

I’m going to do a quick introduction then a brief review of the etiology and overview of the symptoms of mild traumatic brain injury, along with an interpretation of evaluation results and motivational interviewing. Then we'll get into the meat of the treatment aspect of mTBI, starting with attention and memory, then focused on problem-solving, executive dysfunction, word-finding, return to school and work planning, and empowering the survivor. 

Etiology of mTBI

I always like to start by saying that even though it's called mild TBI, I've found that mild TBI is one of the most complex diagnoses to treat. It is definitely not mild. It is an onion with multiple layers that we are digging through.  We ar pulling away all these different layers to really understand our patient or client and how to be of most help to them. Again, I’ll start by saying that mTBI is extremely complex, and anybody who says that mTBI or concussion is not, I'm guessing doesn't have a lot of experience with it.

Some of the most frequent causes of mTBI are falls, motor vehicle accidents such as motor scooters, bikes and cars. Violence, including domestic violence, gunshot wounds, shaken baby syndrome are causes of mTBI.  Shaken baby syndrome is of particular interest right now. During COVID, the incidence of domestic violence has increased in intimate partner violence. Therefore, we may be seeing some increased brain injuries as a result of that.

Sports injuries, of course, are frequently discussed. You'll see a lot of focus on concussion and mild traumatic brain injury in the press related to sports with college, high school, and professional injury.

If you're working with service members and veterans, in particular, you may see some blast injuries, which is one of the most common injuries coming out of the wars in Iraq and Afghanistan.

Overview of mild Traumatic Brain Injury Symptoms

Following a mild TBI, the patient or client might have a headache, fatigue, balance and vision issues, nausea, and vomiting. This could be immediate or some of these, headaches and fatigue in particular, maybe longer-term. At that point, we are starting to get into post-concussion syndrome, which we aren't going to touch on too much during this course. But it is something to look for.

I want to provide a formal definition of a mild traumatic brain injury. The American Congress of Rehabilitative Medicine (ACRM) notes that a patient with mild TBI is a person who's had a traumatically-induced physiological disruption of brain function as manifested by at least one of the following: any period of loss of consciousness or any loss of memory for events immediately before or after the accident; any alteration in mental state at the time of the accident (i.e., feeling dazed, disoriented or confused); and focal neurological deficits that may or may not be transient. But, the severity of the injury does not exceed the following: Loss of consciousness (LOC), is approximately 30 minutes or less. After 30 minutes, the initial Glasgow Coma Scale would be 13-15. Post-traumatic amnesia (PTA) is not greater than 24 hours. Loss of memory or orientation after the event is not greater than 24 hours. Those three factors are what you really want to pay attention to with mild traumatic brain injury.  The ACRM's definition aligns with the Department of Defense's definition when looking specifically at the definition for mild traumatic brain injury.

Cognitive-Communication Symptoms

Specific cognitive-communication symptoms include issues with attention, memory, executive functioning, verbal fluency, complex problem-solving, and occasionally stuttering. These are the most common areas of difficulty in individuals with mTBI. 

Attention

To review from Part 1, the types of attention are focused attention, sustained attention, selective attention, alternating and divided.  Focused is the most basic form of attention. It’s our response to pain or to cold. If you're working with somebody with a severe traumatic brain injury, perhaps somebody who's in a minimally conscious state, they may react to the pain and cold. They may not be reacting to anything else, but if you pinch them hard or do a sternal rub, they're going to react to that. It's your most basic form of attention.

Sustained attention is vigilance or the ability to pay attention for a longer period of time to one thing. For example, paying attention to this webinar for an hour or two, putting together a presentation, completing documentation after a long day of treating patients, or studying for a test all require sustained attention. An example I used to give to my service members and veterans when I worked with them is focusing on a target as a sniper.  That is sustained attention.

Selective attention is paying attention to a single thing amidst other distractions. If you're working in a really busy work environment, at least pre-pandemic places, being able to focus when you have people all around you who are on the phone or typing or talking to each other. I was at an office once and they had a ping pong table. Hearing the ping pong go back and forth while still being able to focus on the task at hand is selective attention.

Alternating attention is being able to turn your attention to various tasks. The example that I usually give is an executive assistant writing an email. The phone rings, they pick up the phone to answer the call, and then they can go right back to writing that email.  It’s the ability to switch attention back to a task without needing to remind yourself of what you were doing. You're alternating between those two tasks.

Then divided attention is really up for debate as to whether it exists or not. There are varying opinions in the literature, but for this course, we'll refer to divided attention as the ability to attend to multiple things at the same time. The debate is if it is real or if it is actually alternating attention. Again, for now, we'll refer to it as divided attention. The example I usually use for that one is driving. You are paying attention to speed, the amount of gas you have, you're paying attention to your passenger, you're paying attention to the radio, if there's a cop behind you, if there are people driving around you.  You are attending to all of these things all at once. 

Memory

Just a quick review of the different types of memory.  There's prospective memory, which is your memory for future events. An example would be what you are doing this coming weekend.  Short-term memory is your ability to remember information over a short period of time.  Working memory is like your scratchpad or your ability to manipulate information and then dump it. For example, doing addition in your head, or a serial sevens task that is given on some of our assessments, recalling someone's phone number before you can write it down or put it in your phone. That's working memory.  Then, long-term memory is the ability to retain things longer term. Explicit memory requires conscious thought to remember the name of a song, your family member's birthday, or your anniversary. Implicit memory is more procedural. It doesn't require conscious memory and it's more rote memory. Tying your shoe, brushing your teeth, driving (although that is debatable), climbing the stairs, and riding a bike are more rote tasks/activities that you don't need to specifically or consciously work through to remember the steps.

Executive Functioning

Executive functioning issues will be seen at least mildly in patients with mTBI. Patients present with difficulty planning and organizing, initiating tasks, and completing tasks. To quickly review the definition of executive functioning, it is the ability to recognize that there's a problem or a task at hand. It is the ability to plan how you're going to do that task, execute a plan, and evaluate the effectiveness of your execution and plan.

Executive dysfunction is when a person has difficulty doing all of those things: planning, organizing, initiating the task, and completing the task. In addition to that, we've probably all seen that decreased filter, or inability to inhibit response, as well as decreased insights. In mild TBI, that may be noticed more in terms of saying things that would usually be kept internally. In more severe cases of TBI, patients may make sexually inappropriate comments or actions. Again, that's all tied to executive dysfunction. There may also be decreased insight, lack of awareness of the injury, or lack of awareness of symptoms or behavior.

Executive functioning ties into memory, attention, and social skills. It involves the ability to sustain attention on the task. For example, if you're trying to plan how to get from point A to point B on an actual map, without using Google Maps, you have to pay attention to actually find your route. You need to remember where you're headed.  If you are doing this by yourself then you don't really need pragmatic skills. But if you're with a friend or a partner who's driving, and they’re trying to navigate, then you're trying to work that pragmatic piece out too. So, executive functioning really does incorporate memory and attention as well.

Verbal Fluency

Verbal fluency, particularly word-finding, is a major issue with mild traumatic brain injury. Many patients report mild word-finding difficulties following mTBIs. They'll say, "I just can't get it out. It's on the tip of my tongue." This is a really frequent symptom, and it’s worth noting that not all standardized word-finding evaluations will pick up on the subtle word-finding changes that patients report.

In my experience, the Boston Naming Test usually does not pick up on some of these more high-level, more finesse-type of word-finding issues. You will need to dig a little bit deeper with additional standardized assessments such as subtests of the Woodcock-Johnson 3.  It's worth looking at the functional aspects during the evaluation as well as in treatment so that you can see what some of these functional areas of difficulty are in terms of verbal fluency.

Stuttering

There is debate about the nature of stuttering following mild traumatic brain injury.  Patients can present with characteristics of stuttering, but you also want to be looking at whether it's a psychogenic stutter or a neurogenic stutter.

Developmental stuttering, according to the DSM-IV, states that the prevalence of stuttering is only one percent, with the majority of cases beginning in childhood in that developmental phase. Developmental stuttering, 80-90 percent of it, occurs by age 6. Neurogenic stuttering is an acquired speech disorder typically following a neurological disease such as stroke or TBI. Psychogenic stuttering is a behavior resulting from physical trauma, emotional trauma, or stress. It's usually a later onset disorder resulting from that trauma or stress.

The differentiator among the three types is that developmental clearly starts in childhood as is not related to trauma, stress, or any neurological deficit. The main differentiator for neurogenic versus psychogenic is that usually a patient who has psychogenic stuttering will present with an immediate, or rapid, response to treatment. (Keep in mind that you will definitely want to coordinate with psychology on this.) Whereas neurogenic stuttering is going to be a longer-term, more hierarchical treatment protocol.

Guiding Principles of Therapeutic Intervention

Before we get into the principles of therapeutic intervention, I am assuming you have already evaluated your patient and you have determined which symptoms they may be presenting. You've already completed a thorough case history and interview of your patient. You know how they sustained their injury or injuries. You have an idea of what their future goals might be. Are they wanting to return to work? Are they still working and having these issues? Are you working with an adolescent who's in school? How are we going to get them the support that they need? You're starting to think through those things. You've done your standardized evaluation.

Let's say you have test results from the behavioral memory tests and tests of everyday attention. You have all of your standardized scores and some functional observational data from seeing your patient outside of the treatment room and your patient interview information. You are now ready to begin planning treatment in a way that engages your patient or client in that treatment. I'm going to talk through a few guiding principles of therapeutic intervention:  

• Recruit resilience 
• Cultivate therapeutic alliance
• Acknowledge multifactorial complexities
• Build a team
• Focus on function
• Promote realistic expectations of recovery

One principle is cultivating a therapeutic alliance. Another is acknowledging the multifactorial complexities of a mild traumatic brain injury. We are peeling away that onion, getting down to the actual injury, the cause of the injury, and acknowledging all the symptoms. We are figuring out the cause and anything else that may be playing a role.  Building a team is another principle. You're going to focus on function, function, function. I can't say it enough. Then you're going to promote realistic expectations of recovery for your patient and their support system whether that is their parents, their spouse, their partner, their friends, their bosses, etc.

Recruit Resilience

We all have resilience. It's your ability to apply core values to handle stress and overcome adversity. In treatment, you are going to ask your patient to recruit their own resilience to engage in the treatment plan.  Most likely, if your patient has mTBI symptoms like word-finding or memory issues (e.g., they're leaving their keys places, they aren't remembering if they locked the door so they have to go back and check, they're leaving their badge at home when they back out of the driveway) that can be very frustrating for them. They're coming to you with frustrations and they may not be feeling very validated.  You're going to ask them to think about a time when they were facing adversity or had to overcome something challenging. What was that source of strength?  For example, I asked somebody what a source of adversity was for him and he cited Ranger school, which is extreme adversity. I said, “Think about when you were going through Ranger school. What was that inner strength that you drew on in order to get through it?” That's an example.

Cultivate Therapeutic Alliance

Then you're going to cultivate that therapeutic alliance. Asking that first question has already helped because you've established a bit of a relationship. It provides the foundation for that therapeutic relationship. In that alliance, your goal is ultimately to transfer the responsibility of the success of the treatment to the patient.

This is different than a typical medical model where you, as the provider, are going to provide all of the answers to your patient and then they're healed and they are discharged. We want patients to be engaged. We want an alliance that will help to empower them and help them to own their treatment.

Acknowledging the Multifactorial Complexities

Headache, pain, sleep, depression, other psychological health disorders add complexity to the mild traumatic brain injury and patients may be experiencing a majority of these symptoms after a mild traumatic brain injury. All of these things deplete the cognitive reserve.  Think about sleep.  If you're not sleeping, whether you have a new baby or you've been pulling an all-nighter, if you're not sleeping then you're not doing anything else very well. The next day, you may not remember things, you may be foggy, you may not be able to pay attention for long periods of time. You may develop a headache.

If you're in pain, it's hard to focus on anything else other than the pain. So, it's creating attention issues and memory issues. If you can't attend then you can't remember. You can see that all of these things really do play a role. It is very complex. 

It is also worth noting the psychological health disorder side of mTBI. If your patient comes in with depression, anxiety, post-traumatic stress disorder, etc., those can mirror symptoms of cognitive dysfunction. A person with depression is going to have difficulty focusing and difficulty remembering.  Somebody with PTSD, because they're so distracted by their anxiety and their surroundings, is not going to be able to focus or remember.  Again, you can see it is so complex and all of these factors play a role.

It's important that during the initial interview, you are getting answers to questions like, “Are you sleeping?” “Are you in pain?” Always ask what level of pain they're in. Use the pain scale, whether you're working in a hospital setting or elsewhere, because it gives you an idea of what level of pain your patient is dealing with. Additionally, ask about medications in any setting because those could also be playing a role in impacting cognitive performance.

Building a Team

You want to build a team around this patient. You want your patient to have a support system. Include family members or other therapeutic partners on that team and ensure that all partners are in sync. It's up to the patient who they want to have on the team. Especially in this mild population, patients are generally making their own decisions, unless they're a child.  In those cases, clearly, the parents would be a part of the team.

If you're working with an adult patient, don't automatically assume that they want their employer to be involved. If they do, that is great because then you can sync everybody up and get everybody on the same page in order to build a team of support around that patient.

Focus on Function

As I mentioned before, focus on function. Understand the patient's strengths, resources, impairments, and co-morbid factors impact daily function. All of those things tie into that multi-factorial complexity piece. Because you have already done a standardized assessment, some functional observational assessment, and have interviewed the patient, you should have a good idea of what the patient's function is.

Promote Realistic Expectations of Recovery

Finally, promote realistic expectations of recovery. You're going to focus on the positive and be realistic. Provide education about recovery and highlight strengths and weaknesses.

Again, it's really about positivity. With mild traumatic brain injury, in particular, there can be a psychological component the longer that the symptoms last. You really want to focus on and explain to the patient, “Yes, you may be experiencing this, but it doesn't necessarily have to keep you from doing X, Y, Z.” It's important to validate what they're going through, but also focus on the positive. Let your patients know that they can make progress. They can recover. But be realistic as well.

Interpretation of Evaluation

I talked about this in Part 1, but the evaluation is made up of informal results, screenings, observations, and formal results. I mentioned the Rivermead Behavioral Memory Test, the Boston Naming, the Test of Everyday Attention. The qualitative evaluation is important, as are the quantitative standardized pieces.

Observation of a patient allows you to see their effort and behavior during evaluation and it plays a large role in the overall assessment. Standardized assessments provide only a little insight into the functional deficits, so you can't always direct goal setting that way. Whereas functional assessment, in any patient population especially in this one, is extremely important because it really gives a snapshot of how the patient is getting by day-to-day with their injury or diagnosis. I usually give the example of being a good test taker versus not being a good test taker. I won't focus too much on that, but maybe you've performed functionally well in high school on the day-to-day, but you're just not a test taker. You're the valedictorian in day-to-day activities, but then you bomb the SAT.  It doesn't mean that you can't get by, it just means that maybe your function is different on that day or you're not a standardized test taker. That's okay.

Motivational Interview

Again, I'm not going to focus a lot on evaluation in this course, but here are some things to think about. Motivational interviewing creates that therapeutic alliance. It empowers your patient. You gather the information and ask your patient to define specific functional performance deficits. You're asking for specific examples. For example, you say to the patient, "You're telling me that you're having difficulty finding words. Can you give me an example of when that recently happened?" Then the patient might say, "Well, I was trying to order my latte in the morning but I couldn't think to ask for five pumps of chai.”  The patient is defining that specific example of a functional performance deficit. This is something that they were doing in their day-to-day. We're not sitting down and having them answer a question on the Boston Naming Test.

Then you're going to “set the hook.” You're going to identify the strengths and weaknesses. If there is one thing they can improve, what would it be? Be sure to make it functional and specific. Describe the situation and use an empathic and engaging counseling style. You want to use the patient's choices.

The patient identified areas of difficulty in functioning to set some goals which really encourages collaboration between the provider and the patient. It respects the patient's autonomy and gets them to talk about how to make the changes themselves. It also engages the patient in the treatment and gets their buy-in.

This is not the typical goal setting that is based on standardized evaluation scores (e.g., “Patient will name five objects starting with the letter D in 30 seconds.”). You're actually doing more functional goal setting. It takes a little bit more time than you typically offer in a session. But, it doesn't have to be a single session. This strategy can be used over several sessions.  It's about building a plan with the patient that’s more specific, more targeted, and more functional, and in the long run, it takes less time.

As a result of the motivational interview, you can also use goal attainment scaling, which is a five-point scale. It can be developed out of the motivational interviewing. It is a method for measuring progress towards highly individualized goals for that patient. It allows for continuous functional evaluation as well. It's typically a five-point scale ranging from negative two to positive two.  The patient rates him or herself and uses the patient-identified functional issues to create their goals.

Treatment: Attention

There are a couple of different treatment options for attention. The first one is Attention Process Training, which is Sohlberg and Mateer's model. We mentioned the attention model earlier, but they also have a whole training. The training starts with focused attention and builds in a hierarchical manner up to divided attention. Some tasks included a scavenger hunt or cancellation tasks.  This is having the patient listen for a certain number while they're canceling out something.  They have to hit a button when they hear the number while they're canceling tasks.

Attention treatment frequently involves working memory as I mentioned before.  APT has that graduated approach based on the need and complexity of the patient. An example would be - even without using APT - reading in a distracting environment. Maybe the client is reading an article as a reading comprehension task, and while they are reading that article, they are also canceling all of the A's that they see in the article. Then you want to see if they can retain the information for reading comprehension and recall the content.

Another task is called Military Occupational Specialty or MOS. From my experience working with service members and veterans, we want to find tasks that really mimic what the patient may have experienced in their day-to-day life.  Try to find some tasks that will help to elicit those functional difficulties. For the MOS, in particular, I worked with Navy Seals. Navy Seals would explain to me that they would wear headphones in which they would get dual communication. In one ear, they might be getting coordinates and in the other ear, they might be getting a description of somebody they should be looking for. Those are two totally different pieces of information coming into both ears. I don't think I could do that on a good day, but they're telling me that this is breaking down for them. They can no longer listen to both pieces of communication at the same time and remain vigilant to whatever they need to be focusing on.  

The scavenger hunt example is good for building complexity. Let’s say your patient is in an unfamiliar environment, such as a hospital, and you’re getting your patient out of the treatment room and bringing them into the larger hospital, which is more distracting. You can ask them to remember to find the coffee shop, for example, and see if they're able to pay attention to their route as they get there. You can build complexity by asking them to count the fire extinguishers along the route. So, they're attending to that while they're also attending to their task of getting to the coffee shop. Again, this is very functional and you're building in complexity as needed.

Treatment: Memory

What did your patient use for memory compensation prior to injury? We all use memory compensation every day. I have a notebook that I take notes in with my little checkboxes. I also use my phone. People use sticky notes.  What did your patient use? Maybe you can use that as a compensatory strategy post- mild traumatic brain injury.

Again, the treatment goal should be dependent on functional, patient-driven future goals. For example, I was talking with somebody the other day who kept forgetting her keys. You can have the person get one of those tiles that actually tracks your keys. You attach it to your phone and your phone will buzz if you get too far away from your keys.

What are some strategies that you can use to ease that cognitive fatigue and strain, and help with compensation? Internal memory strategies are things that you don't need externally, such as using acronyms with the military. That strategy is used often.  Association is another internal strategy.  For example, associating people with animals or fruits if you trying to remember names, etc. Mnemonics is creating a sentence or using the first letter of each word to represent something else. External strategies are tasks like writing things down, putting notes in your phone, setting alarms, etc.

Some additional treatment ideas for memory include asking your patient to e-mail you three things at three separate times.  Ask the individual how they are going to do that?  If they have never used that strategy before suggest to them, “How about you enter these three reminders into your phone, and then it'll remind you so that you don't even have to think about it.” Maybe they are going to email you their date of birth at 1:00 p.m., their last appointment of the day at 6:00 p.m., and with service members, I’ll ask them to email their rank to me at 8:00 a.m. the following morning. Something along those lines.

We can also ask a patient to brainstorm and then use an external memory strategy to assist with medication management or appointment recall. "I know the neurologist just put you a new medication. How are you going to remember how to take those? Let's brainstorm what you think might work for you. Is it going to be a pillbox? Is it going to be an app on your phone? Is it writing it down? Is it creating a sticky note that you'll put on your bathroom mirror? Is it setting the pill bottle on the toilet in the morning to remember to take it?” You are brainstorming with your patient so that they have that buy-in.

Another memory task is to have the patient read an article in the morning and then summarize the article with a partner or spouse at the end of the day. This works on reading comprehension and memory for what they have read, as well as remembering to report it to another individual.

Treatment: Problem-Solving and Executive Dysfunction

Goal Setting and Planning

Spouses and partners often report that patients will start multiple projects and never complete them. I can't tell you how many partners have told me that they are going crazy because they have, for example, a half-tiled bathroom or a half-finished fire pit in the backyard. Baby locks have only been put on half of the cabinet doors in the kitchen or half of the lawn has been mowed.

The patient is unable to execute or initiate the plan. Maybe your patient has five or six tasks they really want to get done around the house, but they just can't initiate it. This is when it is important to work with the team and involve the spouse or partner in the planning to develop project completion plans and ways to motivate the patient to complete those tasks. It is not nagging, but more independent ways to empower the patient.

We talked through some other examples like scavenger hunts and working memory functional tasks (e.g., dual communications example). You want to discuss project completion plans with team members as well as motivational plans for the patient that are effective for him or her. That's really going to help the patient with completing tasks.

Treatment: Word Finding

Word finding difficulties are a significant problem for individuals with mTBI.  When they get that tip of the tongue syndrome strategies such as visualization or scanning the alphabet (i.e., going through each letter of the alphabet in your head) will usually trigger the word they're trying to find. Let's say I'm trying to say the word ‘cognitive’. If I start going through the alphabet, A-B-C, okay, “C – cognitive.” That spurs the thought process. Circumlocution, or talking around the word, is another strategy. Again, using the word 'cognitive', the individual might say, “It's that thing when you're trying to think. It's a way to describe your thinking. It's tied into the brain.”

Pausing is another strategy to help with word finding. Here is an example I used a lot when working with service members and veterans. If you think about some of the most impactful public speakers in history, Martin Luther King Jr., John F. Kennedy Jr., and you play recordings of their speeches, they frequently pause for impact. But in this case, you can use it as an example to show the patient that people aren't going to think it is odd if they pause while speaking. “If you slow down, slow your rate of speech, give yourself the time to think about the word, that really helps with word finding.” That's one activity and a way to build awareness as well. 

A functional word-finding treatment task for a patient who is returning to work is to have them brief the entire treatment team or have them present a topic to the team. This builds on complexity. It could be a hobby or something related to work, which is a bit more complex. Have them build a 10–15-minute presentation. They can use PowerPoint, note cards, or other compensatory strategies. But the idea is to have them brief their team while focusing on word finding, attention, and memory.

Return to Work

Think function, function, function. We talked about giving a presentation to the treatment team as an example of a functional task.  Pragmatic focus in meetings, video call etiquette, what's okay and what's not okay during video calls are all functional activities.  We also want to discuss options about letting their employer know if accommodations are needed. For example, maybe they need to work remotely full-time remote. If their employer is open to that, then that's something to discuss. Maybe they need to start work a little later. However, there is a fine line between letting the employer know and the employer knowing too much.  Awareness is not always a good thing. So we want to work closely with the patient about how much they want their employer to know.

In one regard, an employer knowing can help protect that patient from being fired. If they're having issues at work, they can tap into FMLA or short-term disability, etc.  But work with your patient to see if they think their employer is going to be willing to accommodate and if it will impact their career negatively. It’s worth having the discussion.

Return to School

Early intervention is typically focused on providing services for children who are birth to three years of age.  In some states, it’s birth to two years old.  Special Education under the Individuals Disabilities Act requires the development of an IEP, an individualized education plan. It's a good option for students who have a disability that's adversely impacting education. It's more structured than a 504 plan, which is a less involved process and is used to provide accommodations in a regular education environment. A 504 is put in place for the regular education environment. An IEP can involve removing the student from the regular education environment when additional support is needed. 

Per the CDC guidelines for return to school, most students respond positively to a well-orchestrated short-term plan of physical rest, simple classroom adjustments and slight environmental changes. For example, extra time on the tests, reduced homework load, etc.

Longer-term post-concussion might require a 504 plan focused on physical accommodations such as automatic door openers (I don't think you really need that for a mild, this is just an example), assistant keyboard for taking notes, modified class schedule, shortened school days, those types of accommodations.

The treatment team is very important for returning to school.  The team includes the student’s teacher, the guardians, the school SLP, maybe the school psychologist, special education teachers, etc.  You will want to provide extensive education to family, teachers, and the team. There is a huge lack of awareness about the effects of TBI on learning so you really need to be an advocate for your student and their recovery. But they may need help along the way.

There is also a lack of communication between health care and the school. If you are a school-based SLP, do not hesitate to get that signed permission from your student’s family members.  Call the hospital and talk to the SLP, ask for records from the family, and get that communication going.  Similarly, if you are a health care SLP in the hospital and you know your student is going back to school, pick up the phone with permission of course, and call the school SLP. Get the conversation started.

Empowering the Survivor

Empowering the survivor ties into that motivational interviewing piece. The survivor - your patient, your client, your student - is in charge of their treatment. Involve patients in your treatment planning, hold them accountable, develop accountability within that patient. Your patient or client owns their own treatment.

Encourage short and long-term goal setting. A short-term goal may be, “I want to remember five times to take my meds at the right time.” Whereas a long-term goal is, “I want to go to grad school.” “I want to progress in my company.” There are no limitations to figuring out a way to empower them and build confidence in their skills even post-injury.

I’d like to end with a story. I had a patient who came to me when I was treating service members who was told that he would never work again. He was post-blast injury, had PTSD, and was told he could not go to school and he would never be successful. Basically, he was stuck in “injury mode.” He and I worked together, I brought his spouse in and we talked about how he could return to school. He really wanted to get a graduate degree. We went through a hierarchical treatment where we decided to focus on reading comprehension, then we focused on attention, and then we built tasks and complexity. We did mock tests, we prepped for the GRE etc.  Five years later, he graduated and is now a certified rehabilitation counselor. Empower your patients and your clients that they can do these things. There's nothing holding them back. It may not look exactly like it did before, but there's nothing holding them back.

Questions and Answers

Do you have any suggestions for resources for cancellation tasks?

Actually, you can print out anything. It could be as simple as an article from the newspaper.  Print it out, and say; "I want you to cancel the word 'and' every time you see it.” Have them go through the article. Then you can up the complexity by timing it, you can add noise stimulation, you can ask them to do more than one cancellation, cancel the word 'and', and the word 'the', etc.

Do any of these mTBI symptoms mirror dementia?

Absolutely, you're going to find all of these symptoms in dementia. You're going to find issues with memory, attention, executive dysfunction. I have not personally worked with a patient with dementia who has stuttering issues, so I won't speak to that. But I know word finding and all of that is for sure.  A lot of the characteristics of mTBI, you're going to find in dementia and a lot of the evaluations that are used for evaluating mTBI and the symptoms are used with dementia too.  The MoCA was actually standardized on dementia patients prior to being used in mild traumatic brain injury.

What specific questions can you ask patients to elicit functional performance deficits?

I would start with something super simple, "What's bothering you?” “What brings you here today?” “You mentioned that you were playing soccer and you ended up with a concussion. You're still having symptoms of that. Talk to me about what that looks like on the day-to-day." You barely have to ask and they'll say, "Oh, man, I'm so glad you asked." Let's say this person is in high school, "My teacher called on me the other day and I could not get my words out. I could not get my answer out. I just sat there and all the other kids looked to me like I was dumb." Or, "I had this big meeting for my boss and the only thing he wanted me to do was bring this one folder for him and I left it at home. Which never would have happened before because I had already written it down and used my memory strategies. I put it in my phone and I still forgot it. That never would have happened before."

Those kinds of questions of just asking them, what's going on, what does your day-to-day look like, how is this impacting you, are all great questions to start with. Again, that develops a therapeutic alliance in that relationship as well.

How do we track generalization of these strategies? Team-based, self-report, etc.

With that goal attainment scaling that I mentioned, assuming your patient has good awareness, they're going to be able to rank their progress as they go. I don't get really into the weeds of goal attainment scaling in this course so if you want more information, definitely look up Jim Malek's work. It gets into using the Likert scale that will help with generalization, at least in self-awareness.

If you're lucky enough to work in a team treatment environment, being able to say, "Hey, Neuropsychologist, I'm working on word finding. I'm going to ask my patient to put together a brief presentation for you.  In your next treatment session, can you ask them to present that to you? Can you note and discuss if they're having trouble with word-finding and how it went and come back and report back to me?" That's an ideal treatment situation, but it does show how it can work with the treatment team. We want to lean on these patients with mild injuries who have self-awareness.

I've had patients in the past who did not use external memory compensatory strategies, pre-injury. How do you get them to buy into using external strategies now and carrying it over outside of therapy?

Make it as discreet as possible. Usually, that can be accomplished by using what they're already using every day. If they're carrying a smartphone, if they're using a laptop, if they're using an iPad, encourage them to just set up some routines that way and frame it more in terms of reducing the amount of extra work they have to do later. Stress that when they forget something, they have a routine and no longer need to think about it.   If you need to frame it more around routines, for example, your patient is a marathon runner and their routine is to get up every morning at 4:30 a.m. They run 15 miles and then they're done, but they don't even think about it. They just get up and they go. The same is true for the strategies we want them to use.  Treat it more like you're creating less cognitive fatigue. You're creating less cognitive strain because you're building that routine by using these strategies.

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