Opening the black box of cognitive rehabilitation: Integrating the ICF, RTSS, and PIE.

BACKGROUND: Cognitive rehabilitation is a complex and specialized area of practice, as it aims to support individuals with diverse neuropsychological profiles, personal characteristics, and intersectionalities in achieving meaningful, functional change in personally relevant aspects of their everyday lives. In many ways, cognitive rehabilitation is the epitome of a 'black box': it has complicated internal processes that are mysterious to users. We argue that this complex practice has suffered from a lack of specificity of clinical processes and treatment components, resulting in negative consequences for both providers and clients. AIM: To unpack the black box of cognitive rehabilitation by describing a unifying set of frameworks that can effectively direct clinical practice across clinical disciplines: the International Classification of Functioning, Disability, and Health (ICF), the Rehabilitation Treatment Specification System (RTSS), and the Planning, Implementation, and Evaluation framework (PIE). We present a clinical case that illustrates the application of the three frameworks. CONCLUSION: Implementation of these three integrated frameworks supports clinical reasoning, replication of treatments, and communication across disciplines with the ultimate impact of improving rehabilitation outcomes. The frameworks provide a structure for clinicians to clearly define both the what and the how of treatment, with a level of specificity to maximize both effectiveness and efficiency of intervention.

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.

Interprofessional Collaborative Management of Postconcussion Cognitive Symptoms.

Purpose The purpose of this clinical focus article is to illustrate an interprofessional cognitive rehabilitation approach. Invited experts representing physical medicine and rehabilitation, clinical neuropsychology/rehabilitation psychology, registered nurse care coordination, and speech-language pathology share viewpoints from their discipline to engage in collaborative interventions with the goal of enhancing treatment outcomes. Conclusions Treating the multifactorial symptoms of concussion requires expertise from an interdisciplinary team (IDT) of professionals, contributing unique perspectives and providing integrative services to optimize rehabilitation outcomes for patients. Speech-language pathologists serve an important role on IDTs to deliver personalized, targeted therapies for prolonged or persistent postconcussion cognitive impairment.

Editors' Foreword: Knowledge and Skill Competencies for Speech-Language Pathology Management of Concussion.

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The Implementation of a Personalized Dynamic Approach for the Management of Prolonged Concussion Symptoms.

Purpose This clinical focus article reviews the existing treatment literature on the management of prolonged concussion symptoms (PCS) for specifying treatment components that hold the most promise for effectively targeting functional goals that are disrupted due to cognitive impairments. Current evidence suggests the treatment ingredients of psychoeducation and cognitive strategy instruction can be effective for addressing changes in functioning due to perceived cognitive deficits in attention, working memory, and executive functioning. Based on the literature, we propose a personalized, dynamic approach to managing PCS that is tailored to the symptom profile of the individual client and consists of three phases, treatment setup, implementation of treatment, and discharge plan, in which the implementation phase consists of psychoeducation and strategy training. The unique aspect of this approach is the use of individualized status tracking measures on goal progress as well as strategy use and perceived strategy helpfulness to empirically guide treatment. Client performance directs clinical decisions, and the clinician adapts treatment components in order to facilitate functional change. Conclusion We provide a case example of an adolescent client treated in our university clinic to demonstrate the implementation of the proposed personalized and dynamic approach to PCS management.

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.

Cognitive Rehabilitation for Individuals With Parkinson's Disease: Developing and Piloting an External Aids Treatment Program.

Purpose Cognitive deficits are common in Parkinson's disease (PD) and can have a detrimental effect on daily activities. To date, most cognitive treatments have had an impairment-based focus with primary outcome measures of formal neuropsychological test scores. Few, if any, studies have focused on functional improvement or patient-centered goals. Method Three individuals with idiopathic PD participated in an 8-week pilot treatment program to train for the use of compensatory external aids to achieve personalized goals. Goal attainment scaling was the primary outcome measure, which was independently judged by multiple raters at baseline, postintervention, and 1 month posttreatment and analyzed via T-score analysis. Descriptive measures, including self-report and spouse-report rating scales of cognitive functioning, were employed. Results All 3 participants improved in the majority of their laboratory and home goals posttreatment, as measured by goal attainment scaling, and maintained gains for the majority of goals 1 month posttreatment. Conclusions This is the 1st known study to implement an external aids treatment program with patient-centered goals for individuals with cognitive deficits from PD. Positive outcomes were likely influenced by 3 factors: (a) a theoretically motivated focus on external aids; (b) a well-documented, systematic approach to instruction; and (c) the personalization of goals. Supplemental Material https://doi.org/10.23641/asha.10093493.

Attention Process Training-3 to improve reading comprehension in mild aphasia: A single-case experimental design study.

People with aphasia frequently present with nonlinguistic deficits, in addition to their compromised language abilities, which may contribute to their problems with reading comprehension. Treatment of attention, working memory and executive control may improve reading comprehension in individuals with aphasia, particularly those with mild reading problems. This single-case experimental design study evaluated the efficacy of Attention Process Training-3, an intervention combining direct attention training and metacognitive facilitation, for improving reading comprehension in individuals with mild aphasia. A multiple baseline design across six participants was used to evaluate treatment effects. The primary outcome measure was a maze reading task. Cognitive measures were administered pre- and post-treatment. Visual inspection of graphed maze reading performance data indicated a basic effect between APT-3 and improved maze reading for three of the six participants. Quantitative analyses, using Tau-U, corroborated findings identified through visual analysis. The overall effect size was significant (Tau = .48, p = .01). Results suggest that APT-3 has the potential to improve reading in individuals with aphasia, but that it may be more efficacious under certain conditions. Treatment and participant variables, including intensity of treatment and metacognitive strategy usage, are discussed as potential influences on participants' responsiveness to APT-3.

Measuring conversations after acquired brain injury in 30 minutes or less: a comparison of two pragmatic rating scales.

Primary objective: This study compared the reliability, validity and feasibility of the Pragmatics Rating Scale (PRS) to the Profile of Pragmatic Impairment in Communication (PPIC). It was hypothesized that the PRS would have equivalent reliability and validity and superior feasibility. Research design: A correlational pilot study design was implemented. Methods and procedures: Participants were 15 adults with a history of ABI, who provided two conversation samples each, and 15 adults with no history of ABI, who provided one conversation sample each. Two clinicians used the PRS and PPIC to rate each conversation sample. Main outcomes and results: The results of the PRS showed good discriminative validity between the ABI and non-ABI group, adequate construct validity with the PPIC and the La Trobe Communication Questionnaire, superior interrater reliability to the PPIC, and good test-retest reliability. Also, the PRS demonstrated higher clinical feasibility than the PPIC as measured by mean completion time per sample and ratings on a clinical feasibility survey. Conclusions: These results supported our hypotheses that the PRS is sensitive to aspects of social communication often impaired by ABI, without the feasibility drawbacks of a more complex rating scale.

Read, Understand, Learn, & Excel: Development and Testing of an Automated Reading Strategy Detection Algorithm for Postsecondary Students.

Purpose An important predictor of postsecondary academic success is an individual's reading comprehension skills. Postsecondary readers apply a wide range of behavioral strategies to process text for learning purposes. Currently, no tools exist to detect a reader's use of strategies. The primary aim of this study was to develop Read, Understand, Learn, & Excel, an automated tool designed to detect reading strategy use and explore its accuracy in detecting strategies when students read digital, expository text. Method An iterative design was used to develop the computer algorithm for detecting 9 reading strategies. Twelve undergraduate students read 2 expository texts that were equated for length and complexity. A human observer documented the strategies employed by each reader, whereas the computer used digital sequences to detect the same strategies. Data were then coded and analyzed to determine agreement between the 2 sources of strategy detection (i.e., the computer and the observer). Results Agreement between the computer- and human-coded strategies was 75% or higher for 6 out of the 9 strategies. Only 3 out of the 9 strategies-previewing content, evaluating amount of remaining text, and periodic review and/or iterative summarizing-had less than 60% agreement. Conclusion Read, Understand, Learn, & Excel provides proof of concept that a reader's approach to engaging with academic text can be objectively and automatically captured. Clinical implications and suggestions to improve the sensitivity of the code are discussed. Supplemental Material https://doi.org/10.23641/asha.8204786.

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.

Evaluation of a computer-based prompting intervention to improve essay writing in undergraduates with cognitive impairment after acquired brain injury.

This study evaluated a computer-based prompting intervention for improving expository essay writing after acquired brain injury (ABI). Four undergraduate participants aged 18-21 with mild-moderate ABI and impaired fluid cognition at least 6 months post-injury reported difficulty with the writing process after injury. The study employed a non-concurrent multiple probe across participants, in a single-case design. Outcome measures included essay quality scores and number of revisions to writing counted then coded by type using a revision taxonomy. An inter-scorer agreement procedure was completed for quality scores for 50% of essays, with data indicating that agreement exceeded a goal of 85%. Visual analysis of results showed increased essay quality for all participants in intervention phase compared with baseline, maintained 1 week after. Statistical analyses showed statistically significant results for two of the four participants. The authors discuss external cuing for self-monitoring and tapping of existing writing knowledge as possible explanations for improvement. The study provides preliminary evidence that computer-based prompting has potential to improve writing quality for undergraduates with ABI.

Training adults with acquired brain injury how to help-seek when wayfinding: an understudied critical life skill.

The objective of this study was to investigate the efficacy of a group treatment protocol called NICE (Noticing you have a problem, Identifying the information you need for help, Compensatory strategies, Evaluating progress) to train help-seeking when wayfinding for individuals with acquired brain injury (ABI). Seven participants completed the NICE group treatment in an outpatient rehabilitation department at a university medical centre. A single subject multiple baseline design was employed to evaluate the efficacy of the NICE group treatment. The Social Behaviour Rating Scale and the Executive Function Route-Finding Task- Revised were repeated measures used to evaluate potential changes in help-seeking and wayfinding. Secondary outcome measures included pre- and post-treatment evaluation of social problem solving and social cognition. Results revealed that all participants improved on measures of help-seeking and wayfinding. Patterns of improvement and implications for rehabilitation are discussed. This is the first experimental study to evaluate the treatment of help-seeking behaviours and discuss its application to wayfinding in adults with ABI. Preliminary evidence supports further investigation of the NICE group treatment protocol.

Read, Understand, Learn, & Excel (RULE): Development and Feasibility of a Reading Comprehension Measure for Postsecondary Learners.

Purpose: There is a lack of quick, reliable, and valid standardized reading comprehension assessments appropriate for postsecondary readers. We attempted to address this gap by designing Read, Understand, Learn, & Excel (RULE), a reading comprehension measure that employs sentence verification and recall tasks to assess reading comprehension. This article describes the exploratory study undertaken to construct RULE and then examines the preliminary concurrent validity and alternate form reliability of this measure. Method: The RULE measure was first developed by designing reading stimuli, test items for the sentence verification task, and directions for the recall test for 2 forms based on previous work (Griffiths, Sohlberg, Kirk, Fickas, & Biancarosa, 2016). Thirty undergraduate students who identified themselves as typical readers were administered the RULE measure as well as the Nelson-Denny Reading Test (Brown, Fishco, & Hanna, 1993). Students also completed questionnaires and participated in informal interviews to provide information regarding study and learning habits and academic background. Results: There was preliminary evidence of alternate form reliability between the sentence verification task sets of 2 chapters of RULE (r = .38, p < .05). Preliminary evidence for concurrent validity between RULE and the Nelson-Denny Reading Test was provided by correlation coefficients in the low to moderate range (.03-.38). Conclusion: RULE design and preliminary findings of concurrent validity and alternate form reliability provide "proof of concept" for an ecologically valid testing format that assesses comprehension skills appropriate for the postsecondary level. Suggestions for strengthening validity and reliability of the tool are provided, and clinical contributions of RULE are discussed. Supplemental Material: https://doi.org/10.23641/asha.6987371.

Management of Persistent Cognitive Symptoms After Sport-Related Concussion.

PURPOSE: This case review examines treatments speech-language pathologists at our clinic delivered to middle school, high school, and college students for the management of persistent cognitive symptoms after sport-related concussion. The goal is to examine a range of treatment options, describe clinical rationale for selecting those treatments, and report outcomes in order to identify feasible interventions for systematic evaluation through efficacy research. METHOD: Review of clinic intake data identified 63 cases referred for cognitive rehabilitation over a 36-month period. Twenty-four cases (14 women and 10 men) met selection criteria, including documented sport-related concussion, postconcussion symptoms persisting at least 2 months with deleterious effect on school performance, and enrollment in secondary or postsecondary education. The authors independently coded demographics, treatment approaches, functional goal domains, and outcomes. RESULTS: Treatment approaches fell into 4 broad categories: direct attention training, metacognitive strategy training, training assistive technology for cognition, and psychoeducational supports. Eighty-three percent of clients achieved self-selected functional goals. CONCLUSIONS: Research has focused primarily on return to play and provision of academic accommodations in the initial weeks following concussion. Findings from this case series suggest that speech-language pathologists can deliver individualized interventions that lead to positive clinical outcomes. The authors hope findings encourage efficacy research.

Cognitive Intervention for Attention and Executive Function Impairments in Children With Traumatic Brain Injury: A Pilot Study.

OBJECTIVE: To test the effectiveness of the Attention Improvement and Management (AIM) program, a cognitive intervention for improving impairments in attention and executive functions (EFs) after pediatric traumatic brain injury (TBI). SETTING: Tertiary care children's hospital. PARTICIPANTS: A total of 13 children with complicated mild-to-severe TBI (average of 5 years postinjury) and 11 healthy comparison children aged 9 to 15 years completed the study. DESIGN: Open-label pilot study with a nontreated control group. MAIN MEASURES: Subtests from the Test of Everyday Attention-for Children (TEA-Ch) and the Delis-Kaplan Executive Function System (D-KEFS), the self- and parent-report from the Behavior Rating Inventory of Executive Function (BRIEF), and the Goal Attainment Scale (GAS). RESULTS: Relative to the healthy comparison group, children with TBI demonstrated significant improvement postintervention on a neuropsychological measure of sustained attention, as well as on parent-reported EFs. The majority of families also reported expected or more-than-expected personalized goal attainment. CONCLUSIONS: The study provides preliminary evidence for the effectiveness of AIM in improving parent-reported EFs and personalized real-world goal attainment in children with TBI.

Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury.

Adults with mild to moderate acquired brain injury (ABI) often pursue post-secondary or professional education after their injuries in order to enter or re-enter the job market. An increasing number of these adults report problems with reading-to-learn. The problem is particularly concerning given the growing population of adult survivors of ABI. Despite the rising need, empirical evaluation of reading comprehension interventions for adults with ABI is scarce. This study used a within-subject design to evaluate whether adult college students with ABI with no more than moderate cognitive impairments benefited from using reading comprehension strategies to improve comprehension of expository text. Integrating empirical support from the cognitive rehabilitation and special education literature, the researchers designed a multi-component reading comprehension strategy package. Participants read chapters from an introductory-level college anthropology textbook in two different conditions: strategy and no-strategy. The results indicated that reading comprehension strategy use was associated with recall of more correct information units in immediate and delayed free recall tasks; more efficient recall in the delayed free recall task; and increased accuracy recognising statements from a sentence verification task designed to reflect the local and global coherence of the text. The findings support further research into using reading comprehension strategies as an intervention approach for the adult ABI population. Future research needs include identifying how to match particular reading comprehension strategies to individuals, examining whether reading comprehension performance improves further through the incorporation of systematic training, and evaluating texts from a range of disciplines and genres.

Proposed Criteria for Appraising Goal Attainment Scales Used as Outcome Measures in Rehabilitation Research.

Goal Attainment Scaling (GAS) is a method for writing personalized evaluation scales to quantify progress toward defined rehabilitation goals. In the published literature, GAS methodology is used with different levels of rigor, ranging from precisely written GAS scales that ensure minimal bias and explicitly describe 5 levels of goal attainment to subjective ratings of goal attainment by adjectives (eg, worse/better than expected), which are transformed into a T score, wrongly giving the reader the impression of a truly standardized, interval scale. A drawback of GAS methodology is that it is highly dependent on the ability of the GAS setting team/person to generate valid, reliable, and meaningful scales; therefore, reliability and validity of GAS scales are idiosyncratic to each study. The aims of this article were to (1) increase awareness of potential sources of bias in GAS processes; (2) propose GAS quality appraisal criteria, allowing judgment of the quality of GAS methodology in individual rehabilitation studies; and (3) propose directions to improve GAS implementation to increase its reliability and validity as a research measurement tool. Our proposed quality appraisal criteria are based on critical appraisal of GAS literature and published GAS validity studies that have demonstrated that precision, validity, and reliability can be obtained when using GAS as an outcome measure in clinical trials. We recommend that authors using GAS report accurately how GAS methodology was used based on these criteria.

Developing Brain Injury Interventions on Both Ends of the Treatment Continuum Depends Upon Early Research Partnerships and Feasibility Studies.

PURPOSE: The purpose of this research article is to describe two very different lines of brain injury treatment research, both of which illuminate the benefits of implementation science. METHOD: The article first describes the development and pilot of a computerized cognitive intervention and highlights how adherence to implementation science principles improved the design of the intervention. Second, the article describes the application of implementation science to the development of assistive technology for cognition. RESULTS: The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) and the menu of implementation research strategies by Powell et al. (2012) provide a roadmap for cognitive rehabilitation researchers to attend to factors in the implementation climate that can improve the development, usability, and adoptability of new treatment methods. CONCLUSION: Attention to implementation science research principles has increased the feasibility and efficacy of both impairment-based cognitive rehabilitation programs and assistive technology for cognition.

An Exploratory Study of Reading Comprehension in College Students After Acquired Brain Injury.

PURPOSE: This exploratory study builds on the small body of existing research investigating reading comprehension deficits in college students with acquired brain injury (ABI). METHOD: Twenty-four community college students with ABI completed a battery of questionnaires and standardized tests to characterize self-perceptions of academic reading ability, performance on a standardized reading comprehension measure, and a variety of cognitive functions of this population. Half of the participants in the sample reported traumatic brain injury (n = 12) and half reported nontraumatic ABI (n = 12). RESULTS: College students with both traumatic and nontraumatic ABI cite problems with reading comprehension and academic performance postinjury. Mean performance on a standardized reading measure, the Nelson-Denny Reading Test (Brown, Fischo, & Hanna, 1993), was low to below average and was significantly correlated with performance on the Speed and Capacity of Language Processing Test (Baddeley, Emslie, & Nimmo-Smith, 1992). Injury status of traumatic versus nontraumatic ABI did not differentiate results. Regression analysis showed that measures of verbal attention and suppression obtained from the California Verbal Language Test-II (Delis, Kramer, Kaplan, & Ober, 2000) predicted total scores on the Nelson-Denny Reading Test. CONCLUSIONS: College students with ABI are vulnerable to reading comprehension problems. Results align with other research suggesting that verbal attention and suppression problems may be contributing factors.