Tutorial: The Speech-Language Pathologist's Role in Return to Work for Adults With Traumatic Brain Injury.

PURPOSE: Return to work (RTW) is a major life participation metric used for persons with a traumatic brain injury (TBI). Speech-language pathologists (SLPs) have clinical expertise in the cognitive-communication aspects of TBI. This clinical focus article aims to support the clinical practice of SLPs by summarizing key interprofessional vocational rehabilitation (VR) models and illustrating the role of the SLP throughout the RTW process with a case study. METHOD: This clinical focus article was written by the Academy of Neurologic Communication Disorders and Sciences TBI Research Group along with a VR expert. Authors engaged in deliberative, agenda-based discussions beginning with a literature review based on previous systematic studies. Discussions explored relevant VR and SLP practices. RESULTS: This clinical focus article presents key VR models in parallel with SLP assessment and treatment to illustrate best practice patterns in an RTW field with a dearth of SLP-specific literature. We summarize general VR approaches and four evidence-supported VR models for adults with TBI. We highlight how a model of interprofessional assessment can assist with planning and communication of important work-related concerns. We illustrate how the chronological model of work return can assist with developing goals and planning treatment. CONCLUSIONS: SLPs play an important role in identifying, managing, and collaborating with an RTW team following TBI. A working knowledge of VR models can assist with improving the dialogue between SLPs and VR professionals and can inform practice when working with persons with TBI who have work return as a goal.

Social Communication Following Adult Traumatic Brain Injury: A Scoping Review of Theoretical Models.

Purpose Social communication is the set of abilities that allows individuals to achieve relevant social goals across contexts. Speech-language pathology evaluation and treatment of traumatic brain injury (TBI)-related social communication problems should be informed by evidence-supported theories of social communication. The primary purpose of this article is to summarize the results of a scoping review of theoretical models that speech-language pathologists may apply to the evaluation and treatment of social communication problems of adults with TBI. Method A scoping review was conducted of PubMed, PsycINFO, and Embase for sources published in English between 1989 and 2020 that described human social communication and participation. Resulting sources were systematically examined for social communication models. Results Nine theoretical models were identified that speech-language pathologists may apply to their assessment and treatment of social communication abilities of adults with TBI. Identified models were categorized thematically into one of three classes: cognitive models, social competence models, and pragmatic models. Using a framework developed for the purposes of this article, each identified model was evaluated, and one exemplar model in each class is described in depth. Conclusions Social communication problems in adults post-TBI are common. The existence of multiple models empowers speech-language pathologists to select individual-focused assessment and treatment approaches to maximize intervention outcomes.

Social communication following traumatic brain injury part I: State-of-the-art review of assessment tools.

PURPOSE: The primary aim of this paper was to identify and describe current social communication assessment tools for adults with traumatic brain injury. METHOD: We conducted a state-of-the-art review to identify and categorise the range of social communication assessment tools found in the assessment and treatment literature that revealed 42 measures that were coded according to characteristics related to assessment types, psychometrics, and implementation. RESULT: Of the 42 assessments, 64% evaluated social cognition and the remaining 36% evaluated communication. Coding of implementation categories revealed that only 18/42 (43%) measures were ecologically grounded and 23/42 (55%) were available to clinicians by purchase or in the public domain. Only three measures incorporated questions or an assessment of the examinee's priorities or concerns. CONCLUSION: A number of factors limit current social communication assessment. The lack of tools that objectively and reliably evaluate communication or social cognition in ecologically valid ways remains problematic. Of particular concern is the lack of prioritisation of the individual's communication values and needs. Recommendations include a call to focus research on the development of more contextual, standardised assessments, consider availability and feasibility when tools are being developed, and evaluate assessment processes as well as discrete tools.

Social communication following traumatic brain injury part 2: Identifying effective treatment ingredients.

PURPOSE: Social communication deficits are a severely debilitating aspect of traumatic brain injury (TBI), and there is strong clinical and research interest in how social communication interventions work for this population. Informed by a companion paper targeting assessment of social communication impairments post-TBI, this paper reviews relevant treatment theories and provides an inventory of social communication treatment components. METHOD: We completed a mapping review examining 17 articles from recent literature reviews and 4 updated articles from a literature search to identify treatment targets and ingredients using the Rehabilitation Treatment Specification System (RTSS). RESULT: Social communication interventions are primarily based on behavioural and cognitive treatment theories. Common social communication treatment targets include changing skilled behaviours and cognitive or affective representations. We offer a menu of therapeutic ingredients and treatment considerations which represent the current state of social communication interventions. CONCLUSION: By reviewing the social communication intervention literature through a theoretical lens, we identify which treatment targets are missing, which targets are being addressed, and which therapeutic ingredients (i.e. clinician activities) are recommended. A hypothetical case study is provided as a supplement to demonstrate how speech-language pathologists may integrate treatment theory, ingredients, and targets into clinical practice.

Ethical deliberation: a foundation for evidence-based practice.

Infusing evidence-based practice (EBP) into the clinical setting implies that professionals use evidence that is relevant and credible, maintain their pursuit of best current knowledge, respect their clients' preferences and values, and keep these clients and their families appropriately informed about their treatment options. Thus, rational and judicious EBP must be guided by speech-language pathologists' or audiologists' ethical principles of beneficence, non-maleficence, justice, and autonomy. In this article, we will affirm the centrality of ethical reasoning in EBP by describing what it means to be a professional as reflected in our Code of Ethics, reviewing the principles of ethics that underlie clinical decision making, and demonstrating how an ethical framework can and should provide the context in which EBP is conducted.

A randomised controlled crossover trial evaluating Television Assisted Prompting (TAP) for adults with acquired brain injury.

Assistive technologies for cognition (ATC) provide an effective means to compensate for prospective memory failures among adults with acquired brain injury (ABI; de Joode, van Heugten, Verhey, & van Boxtel, 2010 ; Sohlberg et al., 2007 ). This study evaluated a novel ATC device, the Television Assisted Prompting (TAP) system, which provides audiovisual reminders at scheduled prospective times on a person's home television. A randomised, controlled crossover design evaluated task completion for two preferred, two non-preferred, and two structured experimental tasks among 23 adults with ABI between two conditions: TAP prompting or typical (TYP) practice, without TAP reminders. Main outcomes showed a significant advantage of prospective memory prompting (72% completion) over no prompting (43% completion) and higher task completion with TAP prompting for researcher-assigned experimental tasks (81%) compared to self-selected preferred (68%) or non-preferred (68%) tasks. Results are discussed in the context of ATC efficacy to support prospective memory prompting following ABI, with contributions and future directions for continued investigation of customisation of prompts to maximise task completion.

Phase I evaluation of the television assisted prompting system to increase completion of home exercises among stroke survivors.

PURPOSE. Effective delivery of dysphagia exercises requires intensive repetition, yet many brain injury survivors demonstrate difficulty adhering to home programmes. The Television Assisted Prompting (TAP) system provides a novel method to deliver intensive in-home therapy prompts. Specific research questions compared the effectiveness of the TAP system to typical practice on programme adherence, satisfaction and caregiver burden. METHOD. A within-participant alternating treatment design with random assignment of treatment condition compared exercise programme adherence across TAP and typical practice delivery conditions, replicated across three participants. Data included quantitative programme completion rates, satisfaction survey reports and caregiver burden questionnaire results, as well as qualitative interview findings. RESULTS. A large treatment effect was demonstrated for two participants; exercise programme completion rates increased by 6-17 times typical practice levels with the TAP system. TAP supported sustained practice over the course of the experiment for the third participant despite minimal differences between conditions. Participants reported high satisfaction and endorsed the TAP system. There was no significant change in caregiver burden. CONCLUSION. The TAP system provided a novel assistive tool to support home programme completion of intensive exercise regimens for clients with cognitive impairment and care providers with significant burden. Future research must ensure continued development of a reliable and intuitive system.

When directions fail: Investigation of getting lost behaviour in adults with acquired brain injury.

PRIMARY OBJECTIVE: To investigate and describe getting lost behaviour and wayfinding strategies among acquired brain injury (ABI) survivors and matched controls. RESEARCH DESIGN: Matched control group comparison design. METHODS AND PROCEDURES: This study compared wayfinding performance of 18 adults with acquired brain injury to controls matched for gender, age and education. Participants followed written directions along an eight-step route in an unfamiliar neighbourhood, with three intentionally challenging choice-points. They used a cellular phone to request assistance if they became lost. Dependent measures included accuracy, directness and wayfinding strategy. Statistical and qualitative analyses explored group themes and differences. MAIN RESULTS: Participants with ABI demonstrated significantly greater on-route wayfinding errors and hesitancy than matched controls. The ABI group requested assistance over the cell phone more frequently than controls and required more attempts at re-orientation with concrete, salient directions in order to re-orient in the field. Participants in the control group anticipated errors with greater frequency than those with ABI. CONCLUSIONS: ABI survivors demonstrated greater challenges with wayfinding than matched controls. Re-orientation required concrete, explicit redirection with reference to salient landmarks. Implications for clinical practice and assistive technology are discussed.

How best to orient travellers with acquired brain injury: A comparison of three directional prompts.

PRIMARY OBJECTIVE: To compare the effects of written landmark, cardinal and left/right street directions on navigational success at the beginning of a walking route. RESEARCH DESIGN: Matched control group comparison design. METHODS AND PROCEDURES: This study compared navigational performance of 18 adults with acquired brain injury (ABI) to controls matched for gender, age and education. Participants followed written directions with landmark, cardinal or left/right directions at each of four locations. Dependent measures included accuracy, directness, stated confidence and preference. MAIN RESULTS: Participants with ABI demonstrated greater errors and hesitancy than controls when presented with cardinal and left/right directions. Both groups performed equally well with landmark directions. All participants stated preference for landmark directions. Participants with ABI were more likely to guess or become confused when following cardinal or left/right directions. CONCLUSIONS: Landmarks served as a performance equalizer between groups for navigational performance at the start of a walking route. Implications for the design of navigational assistive tools and future research are discussed.

Public computing options for individuals with cognitive impairments: survey outcomes.

PURPOSE: To examine availability and accessibility of public computing for individuals with cognitive impairment (CI) who reside in the USA. METHOD: A telephone survey was administered as a semi-structured interview to 145 informants representing seven types of public facilities across three geographically distinct regions using a snowball sampling technique. An Internet search of wireless (Wi-Fi) hotspots supplemented the survey. RESULTS: Survey results showed the availability of public computer terminals and Internet hotspots was greatest in the urban sample, followed by the mid-sized and rural cities. Across seven facility types surveyed, libraries had the highest percentage of access barriers, including complex queue procedures, login and password requirements, and limited technical support. University assistive technology centres and facilities with a restricted user policy, such as brain injury centres, had the lowest incidence of access barriers. CONCLUSION: Findings suggest optimal outcomes for people with CI will result from a careful match of technology and the user that takes into account potential barriers and opportunities to computing in an individual's preferred public environments. Trends in public computing, including the emergence of widespread Wi-Fi and limited access to terminals that permit auto-launch applications, should guide development of technology designed for use in public computing environments.

Validation of the Activities of Community Transportation model for individuals with cognitive impairments.

PURPOSE: To develop a theoretical, functional model of community navigation for individuals with cognitive impairments: the Activities of Community Transportation (ACTs). METHODS: Iterative design using qualitative methods (i.e. document review, focus groups and observations). Four agencies providing travel training to adults with cognitive impairments in the USA participated in the validation study. RESULTS: A thorough document review and series of focus groups led to the development of a comprehensive model (ACTs Wheels) delineating the requisite steps and skills for community navigation. The model was validated and updated based on observations of 395 actual trips by travellers with navigational challenges from the four participating agencies. Results revealed that the 'ACTs Wheel' models were complete and comprehensive. CONCLUSIONS: The 'ACTs Wheels' represent a comprehensive model of the steps needed to navigate to destinations using paratransit and fixed-route public transportation systems for travellers with cognitive impairments. Suggestions are made for future investigations of community transportation for this population.

A profile of community navigation in adults with chronic cognitive impairments.

PRIMARY OBJECTIVE: This study sought to identify navigation patterns and illuminate the barriers to and possible solutions for independent community travel in people with chronic cognitive impairments as a result of acquired brain injury. RESEARCH DESIGN: Two investigative methods were used to explore navigation in the population of interest: Study 1 was a field study and study 2 convened a series of focus groups with relevant stakeholders. METHODS AND PROCEDURES: For study 1, each week during a 4 month period, researchers administered a navigational survey and structured interview to a typical case sample of six participants in order to catalogue all trips taken outside the assistive living facility. Study 2 convened six focus groups to access perspectives on navigational issues for individuals with cognitive impairments (CI) from a number of stakeholder groups including individuals with CI, care providers for this population and public transportation workers. CONCLUSIONS: The results of both studies were consistent and indicated that community access is severely restricted for individuals with CI. The majority of trips that were taken tended to be routine and assisted. The variety of travel was limited; participants ventured to the same set places with the same people. Participants described barriers accounting for these problems and suggested a number of strategies to minimize problems.