Assessing Patients with mTBI

Question

Answer

Neuropsychological and cognitive rehabilitations may appear similar, in that there is overlap in the cognitive processes of interest (attention, memory, executive functions, language, perceptual processes, problem solving, etc.) and in some of the measures administered. These two forms of evaluation are often complementary and both are necessary in the management of persons with cognitive deficits who are therapy candidates. The neuropsychological evaluation is often ordered to assess for the presence of, type and severity of deficits, make a cognitive diagnosis, establish a baseline of functioning and to make some predictions of performance in the future. Assessment is usually conducted in a single session, so it provides only a "snapshot" of a person's functioning at one moment in time. As such, neuropsychological evaluations are usually "product" oriented in that the outcome relies heavily on test scores and comparison to statistical norms. Neuropsychologists are psychologists who also have expertise in assessing constructs of intelligence and global psychological functioning which are important to prognosis in a rehabilitation program and to legal/forensic aspects of a patient's situation. Neuropsychological evaluations generally do not provide information on what type(s) of therapy may be effective in treatment.

In contrast to the neuropsychological evaluation, the cognitive rehabilitation evaluation is a therapy-oriented assessment that should focus on the "processes" through which a patient achieves a particular score on a measure to the extent that such processes are transparent. Cognitive rehabilitation evaluations can be honed to allow analysis and inferences regarding different facets of a cognitive area (e.g., different forms of memory e.g., autobiographical, working, procedural) or subprocesses (e.g., encoding, consolidation, retrieval) usually not available in standard neuropsychological testing. Included in the cognitive rehabilitation evaluation is analysis of strategies used spontaneously by the patient and the frequency and effectiveness of their use; thus, a primary focus in this form of evaluation is on an individual's retained abilities. In the cognitive rehabilitation evaluation, a therapist may probe the effectiveness of specific modalities, cues, and strategies on performance not used spontaneously by the test subject as well. A critical component of the cognitive rehabilitation evaluation is assessment of learning capacity for different types of information and how the patient best learns new information (e.g., through visual, verbal, and/or kinesthetic modalities). Flexibility may be provided in the cognitive rehabilitation assessment as well by allowing the patient to demonstrate their performance with any cognitive prostheses they may have (e.g., PDA, augmentative/alternative communication device, etc.). In addition, questionnaires and simulated daily activities are often included in the cognitive rehabilitation evaluation, giving it strong ecological validity. The cognitive rehabilitation evaluation has been described as "ongoing" (Ylvisaker & Feeney, 1998) or "dynamic" (Parente & Hermann, 2003) and often includes criterion based re-assessment at multiple points in a patient's treatment program providing valuable information on the effectiveness of treatment. For additional commentary relevant to this question, the reader is referred to the following references.

Suggested References:

Coelho, C., Ylvisaker, M., & Turkstra, L. (2005). Nonstandardized assessment approaches for individuals with traumatic brain injuries. Seminars in Speech & Language, 26(4), 223-41.

Parente, R. & Herrmann (2003). Retraining cognition: Techniques and applications (2nd edition). Austin, TX: Pro-Ed.

Turkstra, L., Ylvisaker, M., & Coelho, C. (2005). The use of standardized tests for individuals
with cognitive-communication disorders. Seminars in Speech & Language, 26(4), 215-22.

Ylvisaker, M., & Feeney, T. (1998). Collaborative brain injury intervention: Positive everyday routines. Clifton Park, New York: Thomson Delmar Learning.

This Ask the Expert was taken from the course entitled: Mild Traumatic Brain Injury Update presented by Gail Pashek, Ph.D., CCC-SLP, Speech-Language Pathologist, Kansas City Veterans Administration Medical Center.

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Dr. Gail Pashek has extensive experience in clinical management and university teaching in the area of traumatic brain injury. She has conducted research and published articles in the area of neurogenic cognitive-communicative disorders in major journals and is a member of the Academy of Neurogenic Communication Disorders and Sciences (ANCDS), ASHA's Division 2 Neurophysiology and Neurogenic Speech and Language Disorders, and is a regional representative for the National Aphasia Association.