Select Page

7. Cognitive-Communication Treatments Post Acquired Brain Injury

Abbreviations

AAC       Augmentative or Alternative Communication

ABI         Acquired Brain Injury

PCT        Prospective Controlled Trial

RCT        Randomized Controlled Trial

SLP         Speech Language Pathologist

Key Points


Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

Retrieval practice is effective for improving memory recall in individuals with an ABI.

Targeted figurative language therapy improves communication in individuals with chronic TBI.

Text-to-speech technology improves reading rates in individuals with TBI.

Memory group interventions improve memory function post ABI.

Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

Conversation group therapy appears to have a beneficial effect on pragmatic and quality of life concerns following brain injury.

Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

Facial affect recognition training improves emotional perception post ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

Augmentative and alternative communication interventions designed to assist with organization, access, and efficiency of communication may be beneficial for individuals with severe ABI.

Introduction

A common sequela after a brain injury is cognitive impairment, which we know largely predicts rehabilitation outcomes. The primary purpose of this chapter is to review the evidence concerning cognitive-communication disorders and their treatments following moderate to severe acquired brain injury (ABI). For more information regarding cognitive impairments that do not stem from communication deficits, such as memory, attention, and executive functioning, please refer to ERABI Module 6 Cognition.

Prior to 1980, Speech-Language Pathologists (SLPs) working in the area of ABI were uncommon; while there has been a significant expansion in the outcome research and clinical services over the past 15 years, it is apparent from this review that evidence-based research into therapeutic interventions is lagging. This review focuses on communication interventions provided to individuals with brain injury.  There is a limited number of high quality randomized controlled trials (RCTs) within the literature dedicated to cognitive-communication impairments and the therapies performed to assist with the improvement of these deficits. This is especially true for impairments related to linguistic organization, reading comprehension, written expression and information processing. In a review conducted by Perdices et al. (2006) on brain injury, it was found that the majority of studies (39%) were single subject designs, and only 21% were RCTs. Difficulties conducting RCTs with individuals who have sustained an ABI include the complexity of the disorder, the confounding effects of spontaneous recovery, the heterogeneity of this population, costs, specificity of treatment, the need for multifaceted integrated rehabilitation, and the informed consent procedure (Struchen, 2005; Wiseman-Hakes et al., 2010). Further, blinding participants to their treatment group, and team members who are responsible for providing the treatment is “nearly impossible” (Kennedy & Turkstra, 2006).

Bloom and Lahey (1978) define language as, “knowledge of a code for representing ideas about the world through a conventional system of arbitrary signals for communication.”  Language is comprised of some aspect of content or meaning that is coded or represented in a linguistic manner for the purpose of use in a particular context (Bloom & Lahey, 1978). Every aspect of language (content, form and use) includes cognitive processing. Impairment of any cognitive process may affect any or all components of language. It is the mutually dependent relationship between cognition and language that gives individuals the ability to generate, assimilate, retain, retrieve, organize, monitor, respond to and learn from the environment (Kennedy & Deruyter, 1991).

Traditionally, descriptions of communication disorders that exist within populations of individuals with ABI fall into four main groups: apraxia, aphasia, dysarthria and cognitive-communication. The term cognitive-communication disorder was adopted by the American Speech-Language-Hearing Association (American Speech-Language-Hearing Association, 1987) to distinguish the unique characteristics of communication post ABI from those of aphasia following stroke. The College of Audiologists and Speech-Language Pathologists of Ontario defines cognitive-communication disorders as: “…communication impairments resulting from underlying cognitive deficits due to neurological impairment. These are difficulties in communicative competence (listening, speaking, reading, writing, conversation, and social interaction) that result from underlying cognitive impairments (attention, memory, organization, information processing, problem solving and executive functions)” (p.4) (College of Audiologists and Speech Language Pathologists of Ontario, 2002). The study of language disorders following ABI has been challenging; conceivably more than any other area of communication disorders. Clinicians are required to deal with issues of language use or pragmatics to a greater extent than for other acquired neurological communication disorders.  In some instances, the language disorders found among individuals with ABI are more than just a reflection of underlying cognitive deficits. At other times, precise language processing deficits occur in conjunction with cognitively associated communication disorders (Kennedy & Deruyter, 1991).

Many individuals with an ABI, unlike individuals with developmental communication disorders, have a history of normal learning, language and speech. Typically, they are younger than stroke survivors, and have greater concerns regarding transitions back to school and work. The mechanism of injury is unique, and is related to a collection of cognitive-communication disorders. Therefore, it is important to regard individuals with ABI as a distinct group (Turkstra, 1998).

Communication impairments among this group are generally described as non-aphasic in nature (Ylvisaker M & SF, 1994). This is a different type of communication impairment than that seen following stroke, and this distinction is an important one. Communication deficits in individuals with ABI may also include aphasic-like symptoms such as naming errors and word-finding problems, impaired self-monitoring, and auditory recognition impairments. These constraints may also be coupled with other cognitive-communication impairments, such as attention and perception difficulties, impaired memory, impulsivity, and severe impairment of the individual’s overall communicative proficiency within functional situations. These constraints can prevent individuals with ABI from exhibiting even simple communication skills (Lennox & Brune, 1993).

In ABI, communication challenges are often observed along with otherwise intact speech, fluency, comprehension and grammar (Ylvisaker M & SF, 1994). The communication style of those with an ABI has been described as “the language of confusion” (Halpern et al., 1973). In an older study, dysarthria was the most commonly diagnosed communication disorder (54%), followed by other cognitive communication deficits (16%), aphasia (4%) and apraxia of speech (4%) (Duffy, 2005).

Inappropriate/unconventional social behaviour or impaired executive functions (self-awareness of strengths and weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating) are also common areas affected (American Speech-Language-Hearing Association, 1987).

7.2 Communication

There are a number of challenges and difficulties with communication post ABI, some of which include participating in a conversation (retrieving or finding the right word to express oneself), or talking at length about any given topic, formulating sentences, and naming objects or people (Wiseman-Hakes et al., 2010). Despite the variety and availability of treatment materials and strategies aimed at addressing anomia, there is unfortunately a real paucity of studies with strong evidence that meet the inclusion criteria for the ERABI project.

Due to impairments in cognitive abilities following an ABI, difficulties in producing proficient discourse is commonplace. Previous treatments have focused on improving narrative and structured conversations post injury (Kilov et al., 2009). Established treatments often focus on the individual’s ability to communicate with a clinician or researcher but not in the presence of a friend or family member (Jorgensen & Togher, 2009). Whether an individual communicates with a friend, a family member or community member, rather than a trained clinician post brain injury, has had an effect on the language choices made by both partners (Jorgensen & Togher, 2009).

Group treatment may be an effective intervention for individuals post ABI with cognitive-communication deficits, and may be used to target more complex and higher-level skills within the communication domain and with a wide array of communication partners. Within a group treatment setting, patients with ABI gain support and benefit from the experience of their peers within a non-judgmental environment to experiment with compensatory strategies and acquisition of appropriate interaction skills (College of Audiologists and Speech Language Pathologists of Ontario, 2002).

Some specific goals of group treatment post ABI include having individuals focus on having their basic needs met, to improve word fluency, word usage and word finding, and, to have tools to help better organize ideas in conversation. Strategies to ensure meeting these goals is possible would be to implement the use of a yes/no response system, as well as encouraging individuals to speak clearly, with vocal effort and with proper breath support. For clinical use, the Lee Silverman Voice treatment (LSVT®) would be the primary tool when addressing these issues.

7.2.1 Communication Remediation

Key Points

Communicating “yes/no” responses with consistent training and environmental enrichments does not improve communication responses in individuals post ABI.

Targeted figurative language therapy improves communication in individuals with chronic TBI.

Text-to-speech technology improves reading rates in individuals with TBI.

Memory group interventions improve memory function post ABI.

The terms rehabilitation and remediation can often be misused interchangeably; rehabilitation aims at compensatory changes, whereas the goal of remediation is to return to original function. In reviewing the literature with regards to cognitive-communication interventions in ABI, cognitive retaining approaches have been described as “mental muscle building designed to improve aspects of cognition through repetition” (Ylvisaker & Urbanczyk, 1990). While a number of studies have demonstrated statistically significant improvements after intensive cognitive retraining, there have been concerns that the improvements did not translate to functional improvements in daily communication (Ylvisaker & Urbanczyk, 1990). It is important that such interventions translate outside of research studies and make a difference during everyday tasks, and generalize to everyday settings where the individual communicates on a daily basis.

Several authors have reviewed a variety of studies focusing on cognitive-communication therapies used to assist those post ABI (Coelho et al., 1996; Kennedy et al., 2008; MacDonald & Wiseman-Hakes, 2010). In an earlier review conducted by Coelho et al. (1996), the concluding findings suggest that those who sustain an ABI benefit from the work of a SLP. Study authors found evidence to suggest that individuals undergoing therapy showed gains in receptive and expressive language, speech production, reading, writing, and cognition. Further they noted that patients with more severe cognitive-communication deficits are more effectively remediated when treatment is directed toward the development of compensatory rehabilitation strategies such as the use of memory aids (Coelho et al., 1996). Additionally, Coelho and colleagues (1996) reported that although interventions directed at particular cognitive deficits are important, clinicians must attend to broader issues of social skills retraining, timing of treatment during recovery, treatment location and its effectiveness (e.g. hospital, home, school, work). Study results from Mackay et al. (1992) suggest that intervention programs offered earlier post injury result in shorter rehabilitation stays. Further, for individuals with comparable disabilities, those who receive rehabilitation have better than average cost outcomes compared to those not receiving these services (Aronow, 1987). For individuals with profound deficits following their ABI, treatment focusing on environmental modification or the arrangement of permanent support systems may be most effective (e.g. training family members/ significant others to encourage patient/client during activities of daily living) (DePompei & Williams, 1994; Story, 1991).

Discussion

Barreca et al. (2003) compared two rehabilitation approaches that attempted to establish correct responses to yes/no questions. In addition to providing an enriched environment to the first group, a communicative disorders assistant provided yes/no training to the individuals. In addition, the assistant trained healthcare team members and families to follow scripted procedures to increase arousal/attention and to elicit yes/no responses. This was compared against standard care. A trend towards statistical significance for the first group (yes/no training) was found over the second. These findings offer evidence that some patients with severe head injuries improve their ability to communicate “yes/no” responses when undergoing consistent training and environmental enrichments. Increased interactions between patients and nursing were informally observed. As well, families reported on a satisfaction questionnaire that they were better able to communication with their loved one (Barreca et al., 2003).

Another study examined retrieval practice, administered in person, compared to massed restudy and spaced restudy (Sumowski et al., 2014). In the retrieval practice intervention, the participants were first exposed to a verbal paired associate; the subsequent trials for that verbal paired associate were structured as cued recall tests. For individuals with severe TBI and memory-impairments, this retrieval practice was significantly more effective for memory recall than the massed restudy and spaced restudy interventions both immediately following the intervention and at 1 week post (Sumowski et al., 2014).

Technology interventions have also been used to improve communication post TBI. In a study conducted by Harvey et al. (2013) participants completed six sessions of computerized text-to-speech training. Results showed a significant improvement in reading rates during the text-to-speech conditions compared to the no text-to-speech conditions (Harvey et al., 2013). These findings suggest that text-to-speech technology is a useful tool in improving reading rates among individuals with a TBI. However, the authors note that while reading rates improved, comprehension of the written material was not affected.

Brownell et al. (2013) utilized therapy targeting deficiencies in figurative language. All participants completed 10 sessions of word task training resulting in significant improvements in oral metaphor interpretation (Brownell et al., 2013). Participants in the study were approximately eight years post injury suggesting that post TBI individuals are capable of advanced improvements in non-literal language even after the period of rapid and pronounced spontaneous recovery.

In a study by O’Neil-Pirozzi et al. (2010), individuals with ABI participated in twelve 90-minute sessions which were held twice a week. The intervention included memory education, and to improve memory function the study emphasized internal strategy acquisition. Primary emphasis was placed on semantic association followed by semantic elaboration/chaining and imagery.  Results from the Hopkins Verbal Learning Test (HVLT) indicated significant differences between the groups and those with a severe ABI performed more poorly than those with a moderate injury. Despite this finding, those with severe ABIs did perform better than those in the control group. In all, memory performance was seen to improve for all in the intervention group compared to the control group.

Conclusions

There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

There is level 4 evidence that targeted therapy towards figurative language improves communication in chronic TBI individuals.

There is level 4 evidence that text-to-speech technology improves reading rates post ABI.

There is level 2 evidence suggesting memory group interventions can improve everyday memory functioning post ABI.

7.2.2 Social Communication Training

Key Points

Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.

Goal-driven interventions may be effective in improving social communication skills and goals following TBI.

Conversation group therapy appears to have a beneficial effect on pragmatic and quality of life concerns following brain injury.

ABI can influence every aspect of life including physicality, cognitive function, emotional responses, and social functioning. Communication remediation focuses on one’s ability to improve expressive language, speech production, reading, writing, and cognition. Social communication training more specifically addresses social competence and removing barriers to returning to a meaningful and productive life, which includes having the ability to sustain interpersonal relationships (Braden et al., 2010).

Discussion

An RCT by Westerhof-Evers et al. (2017) compared the use of a Social cognition and Emotion regulation treatment (T-ScEmo) to a treatment for general cognitive gains (control group), to evaluate how participants performed on emotion perception, social understanding, and social behavior. The T-ScEmo group had statistically significant improvements on emotion perception (facial affect recognition), theory of mind, proxy-rated empathic behavior, societal participation, and treatment goal attainment, when compared with the Cogniplus group (Westerhof-Evers et al., 2017). Participants in the T-ScEmo group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the Cogniplus group.

In an RCT conducted by Dahlberg et al. (2007) it was found that subjects in the experimental group, when exposed to twelve, 1.5 hour communication sessions, significantly improved their scores on the general participation in conversation subscale on the Profile of Functional Impairment in Communication and the Social Communication Skills questionnaire-adapted (Dahlberg et al., 2007). These improvements were also noted at 6 and 9 month follow up periods. Therefore, this treatment model shows promise for improving social communication skills in an ABI population.

Finch et al., (2017) conducted pre-post study in adults with brain injury aimed at improving and maintaining social communication skills, in particular, the study authors focused on improved perceived communication skills, and achievement of goals. The results from this study indicated that goal-driven interventions may help individuals with TBI achieve social communication goals.

The Braden et al. (2010) study examined the efficacy of the Group Interactive Structured Treatment (GIST) for social competence in a cohort study examining 30 individuals greater than one year post ABI. The 13 week training covered the following topics: skills of the great communicator, self-assessment and goal setting, starting conversations, keeping conversations going and using feedback, assertiveness in solving problems, practice in the community, social confidence through positive self-talk, social boundaries, videotaping, video review, conflict resolution, closure and celebration (Braden et al., 2010). Overall, data gathered from several subjective social communication tools supported the hypothesis that social communication skills and social competence can be improved several years post injury. Further, the program seemed to be effective for individuals with TBI who also have comorbidities.

Although interventions addressing social skills have been studied in detail in other populations, including mental health; in individuals with ABI, there is limited evidenced-based research addressing this area.

Conclusions

There is level 1b evidence that pragmatic interventions including role-playing, improve a variety of social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

There is level 2 evidence that conversation group therapy has a beneficial effect on pragmatic and quality of life concerns in individuals with an ABI.

7.2.3 Training Communication Partners

Key Points

Providing communication training to individuals who interact with people with TBI is effective and encourages two-way dialogue.

Providing training to the communication partner and the individual with TBI together is more effective than training the individual with TBI alone.

The success of communication interventions often relies on the understanding, compliance and competence of communication partners. Training of communication partners has become a central component of communication interventions with many populations. This development is consistent with the World Health Organization (2001) emphasis on context (environmental and attitudinal) as a determinant in health and disability outcomes. Training of communication partners has been shown to have a positive effect on communication effectiveness and reacquisition of communication skills in children with language disorders and developmental disabilities (Girolametto et al., 1994), adults with aphasia (Kagan et al., 2001), adults with dementia (Ripich et al., 1999), and adults with ABI (Togher et al., 2004).

It is not surprising that following an ABI, individuals may have difficulty engaging in meaningful conversation with others. Training communication partners is particularly helpful in successfully facilitating communication with those with moderate to severe ABI. The strategies that are most useful in ensuring success of treatment include speaking in short, simple sentences, making and maintaining eye contact, and asking the patient to repeat the messages being conveyed (Behn et al., 2013). Also, asking patients to clarify they understand the information and repeating the information when necessary, while allowing adequate time to receive an answer. Presenting the information in written form can also elicit a positive outcome from patients (Behn et al., 2013). Eliminating environmental distractions will be a tremendous aid to allow proper focus and attention for optimal results. Communication partners should present choices to patients and clarify the intent of the message being delivered. Using a variety of modes of communication (such as nonverbal) can also be a useful strategy (Behn et al., 2012, Togher et al., 2004, Togher et al., 2016, Sim et al., 2013, Togher et al. 2013).

Discussion

In a RCT conducted by Togher et al. (2004), the benefits of training individuals regarding how to effectively communicate with individuals post ABI was evident. Police officers were trained to respond to individuals with ABI, while the remaining officers who volunteered did not participate in the training. Overall, it was noted that trained officers significantly reduced the number of inquiries required to gain the necessary information from their callers, as well as spent less time establishing the nature of the service request and more time answering the questions being presented.

Behn et al. (2012) found that training allowed for caregivers to interact more easily with the individual with a TBI and encouraged a two-way dialogue. The training in this study was a number of didactic and performance-based approaches such as modeling, role-playing, feedback and rehearsal. As well, the strategies used were both elaborative and collaborative.

When looking at training communication partners, the most efficacious way to improve interactions is to have both the individual with an ABI and their communication partner participate in training together. Two studies by Togher et al. (2013; 2016) found that those who completed social communication training together, made significantly greater gains in participation and overall communication compared to individuals with TBI who attended alone or those who received no training. In a similar study, providing training to communication partners allowed for their communication styles to be modified, which in turn allowed for the individual with TBI to improve their communication (Sim et al., 2013). This study highlighted the benefits of monitoring the two-way interaction using discourse analysis to ensure that information is given, received, and negotiated in an effective and appropriate way (Sim et al., 2013).

Conclusions

There is level 2 evidence to support the effectiveness of interventions that focus on training the communication partners of individuals with severe TBI.

There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

7.3 Non-Verbal Communication

After an ABI, issues may present in either verbal or nonverbal communication skills; Difficulties with conversation may include topic introduction, topic maintenance, topic choice, turn taking and perspective taking (College of Audiologists and Speech Language Pathologists of Ontario, 2002)

Pragmatics describes “a person’s ability to perceive, interpret and respond to the contextual and situational demands of conversation” (Wiseman-Hakes et al., 1998). In other words, pragmatics refers to the interaction between language behavior and the context in which language occurs (Strauss HM & RS, 1994).  Studies have shown that the conversations of individuals with ABI, compared to individuals without injury, have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation, frustration, and a sense of helplessness (Kilov et al., 2009; Sarno et al., 1986).

Goals of treatment regarding non-verbal communication post ABI include initiating conversation with others, learning to understand the emotion presented in verbal language, the ability to respond appropriately, and to maintain conversation. In order to achieve these goals, the necessary strategies to be employed consist of environmental and behavioural modification, counselling and support, pragmatic skills trailing, and targeted speech and language therapy. Patients will require positive reinforcement of the appropriate responses, as well as auditory/visual feedback by others.

7.3.1 Emotional Intelligence

Key Points

Facial affect recognition training improves emotional perception post ABI.

Short intervention designed to improve emotional prosody is not effective post ABI.

Cognitive Pragmatic Treatment (CPT) program is effective at improving comprehension and production of a communication act.

Discussion

Westerhof-Evers et al. (2017) conducted an RCT that is outlined in Table 7.2 describing social communication training. Not only did this study evaluate social understanding and social behaviour, it also examined emotional regulation and perception. On the emotional intelligence components of the study, the experimental group improved significantly on the facial affect recognition (Westerhof-Evers et al. 2017). Participants in the experimental group also reported higher quality of life and their life partners rated relationship quality to be higher than those in the control group (Westerhof-Evers et al. 2017).

A short treatment aimed at improving the ability to recognize emotional prosody was overall found to be ineffective (McDonald et al., 2013). Activities consisted of mostly games designed to focus on prosodic cues but found no change related to communication competence. Significance was approached for the treatment group in terms of improvements in the accuracy on the prosody task and ratings of intensity of emotions. However, participants in the treatment group self-reported that their ability to comprehend daily conversations had improved (McDonald et al., 2013).

Radice-Neumann et al. (2009) and Neumann et al. (2015) demonstrated that training focused on emotional processing can be effective when introduced to a group of individuals who had sustained an ABI. They assert that individuals with ABI can re-learn affective recognition skills. Two interventions to enhance emotion processing were utilized in both studies. The first intervention (Facial Affect Recognition), focused on attention to important visual information and attention to the participant’s own emotional experience. The second intervention (Stories of Emotional Inference) taught patients to read emotions from contextual cues presented in stories and then relate these stories to personal events. Participants who received Facial Affect Recognition training had more positive outcomes. Participants were better at reading faces (emotions) and were more descriptive in relating how they or others would feel in a similar situation. Decreased level of aggression was an additional finding. The Stories of Emotional Inference group produced fewer improvements; however, they were able to make more emotional inferences about how they would feel in a given context. They did not make improvements in their ability to infer how others would feel in a given situation. The authors hypothesized that this might be related to self-centeredness, a trait often attributed to individuals post ABI (Radice-Neumann et al., 2009). However, Neumann et al. (2015) notes that the ability to identify one’s own emotions is an important precursor to recognizing the emotions of others and therefore, should not be dismissed prematurely.

Gabbatore et al., (2015) evaluated a cognitive pragmatic rehabilitation program aimed at improving communicative-pragmatic abilities, in particular self-awareness and executive functioning. Study authors aimed at improving comprehension and production of a communication act. No improvements in comprehension were found from baseline to pre-training (p=0.41), however, significant improvements were demonstrated at post-training and follow-up (Gabbatore et al., 2015).

Conclusions

There is level 1b evidence that facial affect recognition training is beneficial at improving the emotional perception of individuals with ABI.

There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI.

There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

7.4 Alternative Communication Strategies

Following severe ABI, patients present with significant communication challenges that interfere with daily communication needs. Whereas those who sustain a mild or moderate ABI may be more readily able to communicate using natural speech with minor difficulties, those with severe ABI may not be able to meet communication needs through speech alone and may benefit from an augmentative or alternative communication (AAC) strategy (M. S. Bourgeois et al., 2001; Burke et al., 2004; de Joode et al., 2012; Fager et al., 2006; Johannsen-Horbach et al., 1985). Many individuals eventually recover their speech abilities post ABI, but there are still many who remain unable to speak for extended periods of time (Fager et al., 2006). For this specific group, assessments and AAC interventions may be a continual process, ensuring that the individual’s level of function is matched appropriately with new systems as needed (Fager et al., 2006).

In the AAC domain, there are divisions of complexity that include simple, low-tech options (e.g. alphabet boards, picture-based communication boards, memory books, conversation books, day planners) and high tech options that include Voice Output Communication Aids (i.e., Dynavox, McCaw, Message Mate, Big Mack, Voice Pal and Boardmaker) (Fager et al., 2006). Notably, both low-tech and high-tech solutions to communication difficulties may have access that is either direct (i.e. touching/ pointing) or indirect (i.e. switch access or partner-assisted scanning).

Clinicians working in the area of AAC or Assistive/Enabling Technology are well acquainted with the recent explosion of technology options available. Presently, clinicians and patients have access to an extensive set of devices and peripherals including but not limited to iPad, Android, and Windows based tablets as well as a wide variety of associated applications and software (e.g. Proloquo2go, Talking Tiles). Changes in cost, improved ease of access/availability in mainstream retail, and rapid changes in the technology itself and associated applications have resulted in AAC clinical practice that is both invigorating and exhausting. Given that we are in the midst of an unprecedented technology growth, the research in this area is lagging and limited.

In this particular area, difficulties sustained post ABI include verbal expression and severe dysarthria, with the primary goal of treatment being to allow individuals with severe ABI to efficiently access and communicate effectively via AAC. Particular treatment strategies for ACC may be to complete an initial assessment of the individuals needs from access and communication perspectives. From there, clinicians are able to determine the best device and method of access for individuals on a one-to-one basis (taking into account age and gender). And finally, to allow time for training and teaching of both patient and communication partners (i.e. facilitator).

While there is a great deal of discussion around the importance of AAC, there is limited literature supporting the effectiveness of the strategies currently available for ABI populations. Further research is required in order to understand how these communication approaches or alternatives work to benefit individuals with an ABI and their care giving team.

7.4.1 Organizational Word Retrieval Strategies:

Burke et al. (2004) studied the use of three organizational word retrieval strategies for adults with ABI who use AAC. These organizational strategies included semantic topic, geographic place, and first letter of alphabet. While the subjects retrieved words more accurately when using the alphabet organization strategy, they expressed the preference for use of the semantic topic strategy. Clinicians may consider providing these three strategies for clients using AAC, and assisting with identification of the most beneficial and preferred strategy for the individual client.

7.4.10 Sign Language:

All the above AAC treatments are considered to be “aided” forms of communication, meaning they require external support by way of auxiliary materials (communication board, printed words, etc.) (Sigafoos & Drasgow, 2001). In contrast, natural gestures and sign language are forms of “unaided” AAC (Sigafoos & Drasgow, 2001)American Sign Language is the most commonly used, however there are other systems including Pidgin Signed English (PSE), and Signed Exact English (SEE). The advantages of sign language as an AAC are that it is portable (it does not require materials or devices), and it can be easier to teach than speech; communication partners, and clinicians can help individuals with hand formations (Sigafoos & Drasgow, 2001). There is no literature to support use of sign language in brain injured populations specifically, therefore more research in this field is required to make conclusions about its efficacy as a potential therapy.

7.4.2 Non-Electronic Communication Board:

Assistive devices for AAC range in their properties and capabilities. Non-electronic communication boards, along with electronic counterparts, can aid individuals post ABI with messages and symbols depicted on the display. However, the number of messages they can display are limited, and they do not have the capacity for speech output (Iacono et al., 2011). This option would be ideal for people with complex communication needs, as they are easy to access, less expensive, and generally more easy to use by patients, caregivers and clinicians.

7.4.3 Eye-Gaze Communication Board:

Assistive technologies aim to improve outcomes in individuals with physical and cognitive impairments. Gaze-based communication boards use computers controlled by the individual’s eyes. This device replaces keyboard and mouse with eye gaze for those who have physical impairments that prevents the use of upper limb motor function (Borgestig et al., 2016). By using their eyes, individuals can control the computer and gain access to communication and activities, including playing games, music, and perform a range of activities that they would not otherwise be physically able to do (Borgestig et al., 2016). The limitation of this technology is that is not as cost effective as other AAC devices, and novice users may experience fatigue quickly, as there is a substantial learning curve with the type of specific eye movements needed to operate the communication board (it does not mimic natural/intuitive eye movements required for daily activities) (Borgestig et al., 2016).

7.4.4 Bliss Symbols:

Bliss symbols or boards have been available and utilized for several years. The use of these symbols has been found to be very effective with those who have been diagnosed with aphasia or Broca’s aphasia (Rajaram et al., 2012). However, there is little in the literature specific pertaining to individuals with an ABI.

7.4.5 Pictograms:

Pictorgrams allow individuals to express their thoughts, emotions, wants and needs with pictures, as there is not a verbal explanation of all words. Pictogram-based ACC has been used for >30 years and has been shown to help learn new linguistic skills(Pahisa-Solé & Herrera-Joancomartí, 2017).

7.4.6 Picture/Symbol Based Boards:

Despite the surge in technology, picture and symbol based boards remain in high use today (e.g. pictograms, Boardmaker). These symbols or pictures may represent a concept, object, activity, place or event. Symbols, pictures, and boards in general may be used with minimal training and software may be individualized (Bhatnagar SC & F, 1999). The selection of symbols should be appropriate to the individual’s communicative needs. Picture/symbol software is also available for computers, iPads, and iPhones.

7.4.7 Alphabet Boards:

Individuals with dysarthria or who are non-verbal may benefit from an alphabet board. These boards are helpful for spelling single word or short phrase messages. Board sizes may vary depending on the person’s abilities, necessity, or access (Bhatnagar SC & F, 1999). A lexical communication board is another type of AAC that uses common words such as nouns, pronouns, verbs and adjectives to improve sentence formation in patients, however this is not supported by academic sources and therefore requires further research.

7.4.8 Memory Aids:

The use of memory aids as an AAC tool has been studied extensively in patients with dementia and Alzheimer’s, however their use in individuals with an ABI are not well documented. There are a number of different aids that can be used to compensate for memory loss, and decline of cognitive and linguistic skills. Memory books are amongst the most popular and capitalize on procedural memory skills (page turning and reading aloud), they also promote transfer of information and increase social closeness (M. Bourgeois et al., 2001). Memory aids help compensate for memory loss by helping to access stored information and memories, therefore they can be an extremely effective tool that are easily accessible and straightforward to use from a patient’s perspective (M. Bourgeois et al., 2001)

7.4.9 Synthetic Voice:

Synthetic voice, or synthesized speech uses computer-generated text-to-speech synthesis to extract speech and sound components from words and then combine them to form a natural sounding voice (JL Flaubert, 2017)This differs from digitized speech, which uses human voices stored as segments of sounds waves. Synthesized speech is ideal because it allows greater message flexibility and accuracy of what the individual is trying to convey (JL Flaubert, 2017).

7.5 Conclusion

Cognitive-Communication post-ABI represents a unique area of rehabilitation. Cognitive communication deficits are primarily treated by SLPs, and can include both verbal and non-verbal communication, such as emotional intelligence. For other cognitive deficits related to attention, memory, and executive functioning please see Module 6.

Summary


There is level 1b evidence that yes/no training and an enriched environment does not significantly improve communication responses in individuals with an ABI.

There is level 4 evidence that retrieval practice is more effective for memory recall in individuals with an ABI than massed restudy (i.e., cramming) and spaced restudy (i.e., distributed learning).

There is level 4 evidence that targeted therapy towards figurative language improves communication in chronic TBI individuals.

There is level 4 evidence that text-to-speech technology improves reading rates post ABI.

There is level 2 evidence suggesting memory group interventions can improve everyday memory functioning post ABI.

There is level 1b evidence that pragmatic interventions including role-playing, improve a variety of social communication skills in individuals with an ABI, as well as self-concept and self-confidence in social communications.

There is level 4 evidence suggesting that a goal-driven, metacognitive approach to intervention may be beneficial in assisting individuals with TBI to achieve social communication goals.

There is level 2 evidence that conversation group therapy has a beneficial effect on pragmatic and quality of life concerns in individuals with an ABI.

There is level 2 evidence to support the effectiveness of interventions that focus on training the communication partners of individuals with severe TBI.

There is level 2 evidence that providing training to both the communication partner and the individual with a TBI together is more effective than only training the individual with TBI alone or no training at all.

There is level 1b evidence that facial affect recognition training is beneficial at improving the emotional perception of individuals with ABI.

There is level 1b evidence that short intervention designed to improve the ability to recognize emotional prosody was minimally effective in individuals with ABI.

There is level 4 evidence that a Cognitive Pragmatic Treatment (CPT) program is effective in improving communicative-pragmatic abilities in individuals with ABI.

References

American Speech-Language-Hearing Association. (1987). The role of speech-language pathologists in the habilitation and rehabilitation of cognitively impaired individuals: a report of the Subcommittee on Language and Cognition (0001-2475 (Print)

0001-2475). Retrieved from

Aronow, H. U. (1987). Rehabilitation effectiveness with severe brain injury: Translating research into policy. Journal of Head Trauma Rehabilitation, 2(3), 24-36.

Barreca, S., Velikonja, D., Brown, L., Williams, L., Davis, L., & Sigouin, C. S. (2003). Evaluation of the effectiveness of two clinical training procedures to elicit yes/no responses from patients with a severe acquired brain injury: a randomized single-subject design. Brain Inj, 17(12), 1065-1075.

Behn, N., Togher, L., Power, E., & Heard, R. (2012). Evaluating communication training for paid carers of people with traumatic brain injury. Brain Inj, 26(13-14), 1702-1715.

Bhatnagar SC, & F, S. (1999). Communicating with nonverbal patients in India: Inexpensive augmentative communication devices.   Retrieved from http://www.dinf.ne.jp/doc/english/asia/resource/apdrj/z13jo0400/z13jo0405.html

Bloom, L., & Lahey, M. (1978). Language development and language disorders. New York: Wiley.

Bond, F., & Godfrey, H. P. (1997). Conversation with traumatically brain-injured individuals: a controlled study of behavioural changes and their impact. Brain Inj, 11(5), 319-329.

Borgestig, M., Sandqvist, J., Parsons, R., Falkmer, T., & Hemmingsson, H. (2016). Eye gaze performance for children with severe physical impairments using gaze-based assistive technology: a longitudinal study. Assistive technology, 28(2), 93.

Bourgeois, M., Dijkstra, K., Burgio, L., & Allen-Burge, R. (2001). Memory aids as an augmentative and alternative communication strategy for nursing home residents with dementia. Augmentative and Alternative Communication, 17(3), 196-210.

Bourgeois, M. S., Dijkstra, K., Burgio, L., & Allen-Burge, R. (2001). Memory aids as an augmentative and alternative communication strategy for nursing home residents with dementia. AAC: Augmentative and Alternative Communication, 17(3), 196-210.

Braden, C., Hawley, L., Newman, J., Morey, C., Gerber, D., & Harrison-Felix, C. (2010). Social communication skills group treatment: a feasibility study for persons with traumatic brain injury and comorbid conditions. Brain Inj, 24(11), 1298-1310.

Brownell, H., Lundgren, K., Cayer-Meade, C., Milione, J., Katz, D. I., & Kearns, K. (2013). Treatment of metaphor interpretation deficits subsequent to traumatic brain injury. The Journal of Head Trauma Rehabilitation, 28(6), 446-452.

Burke, R., Beukelman, D. R., & Hux, K. (2004). Accuracy, efficiency and preferences of survivors of traumatic brain injury when using three organization strategies to retrieve words. Brain Inj, 18(5), 497-507.

Coelho, C. A., DeRuyter, F., & Stein, M. (1996). Treatment efficacy: cognitive-communicative disorders resulting from traumatic brain injury in adults. J Speech Hear Res, 39(5), S5-17.

College of Audiologists and Speech Language Pathologists of Ontario. (2002). Preferred practice guideline for cognitive-communication disorders.   Retrieved from http://www.caslpo.com/Portals/0/ppg/ppg_ccd.pdf

Dahlberg, C. A., Cusick, C. P., Hawley, L. A., Newman, J. K., Morey, C. E., Harrison-Felix, C. L., & Whiteneck, G. G. (2007). Treatment Efficacy of Social Communication Skills Training After Traumatic Brain Injury: A Randomized Treatment and Deferred Treatment Controlled Trial. Arch Phys Med Rehabil, 88(12), 1561-1573.

de Joode, E., Proot, I., Slegers, K., van Heugten, C., Verhey, F., & van Boxtel, M. (2012). The use of standard calendar software by individuals with acquired brain injury and cognitive complaints: a mixed methods study. Disability and Rehabilitation: Assistive Technology, 7(5), 389-398.

DePompei, R., & Williams, J. (1994). Working with families after TBI: A family-centered approach. Topics in Language Disorders, 15(1), 68-81.

Duffy, J. (2005). Defining, understanding and categorizing motor speech disorder. Motor speech disorders – substrates differential diagnosis, and management. (2nd ed., pp. 3-16 ). St. Louis, MO: Elseiver Mosby.

Fager, S., Hux, K., Beukelman, D. R., & Karantounis, R. (2006). Augmentative and alternative communication use and acceptance by adults with traumatic brain injury. Augment Altern Commun, 22(1), 37-47.

Finch, E., Cornwell, P., Copley, A., Doig, E., & Fleming, J. (2017). Remediation of social communication impairments following traumatic brain injury using metacognitive strategy intervention: a pilot study. Brain Inj, 31(13-14), 1830-1839.

Gabbatore, I., Sacco, K., Angeleri, R., Zettin, M., Bara, B. G., & Bosco, F. M. (2015). Cognitive Pragmatic Treatment: A rehabilitative program for traumatic brain injury individuals. The Journal of Head Trauma Rehabilitation, 30(5), E14-E28.

Girolametto, L., Verbey, M., & Tannock, R. (1994). Improving Joint Engagement in Parent-Child Interaction An Intervention Study. Journal of Early Intervention, 18(2), 155-167.

Halpern, H., Darley, F. L., & Brown, J. R. (1973). Differential language and neurologic characteristics in cerebral involvement. Journal of Speech and Hearing Disorders, 38(2), 162-173.

Harvey, J., Hux, K., Scott, N., & Snell, J. (2013). Text-to-speech technology effects on reading rate and comprehension by adults with traumatic brain injury. Brain Inj, 27(12), 1388-1394.

Iacono, T., Lyon, K., & West, D. (2011). Non-electronic communication aids for people with complex communication needs. International Journal of Speech-Language Pathology, 13(5), 399-410.

JL Flaubert, C. S., AM Jette. (2017). The Promise of Assistive Technology to Enhance Activity and Work Participation.: National Academies of Sciences.

Johannsen-Horbach, H., Cegla, B., Mager, U., Schempp, B., & Wallesch, C. W. (1985). Treatment of chronic global aphasia with a nonverbal communication system. Brain and Language, 24(1), 74-82.

Jorgensen, M., & Togher, L. (2009). Narrative after traumatic brain injury: A comparison of monologic and jointly-produced discourse. Brain Injury, 23(9), 727-740.

Kagan, A., Black, S. E., Duchan, J. F., Simmons-Mackie, N., & Square, P. (2001). Training Volunteers as Conversation Partners Using “Supported Conversation for Adults with Aphasia” (SCA): A Controlled Trial. Journal of Speech, Language, and Hearing Research, 44(3), 624-638.

Kennedy, M., & Deruyter, F. (1991). Cognitive and language bases for communication disorders. Communication disorders following traumatic brain injury: Management of cognitive, language, and motor impairments, 123-190.

Kennedy, M., & Turkstra, L. (2006). Group intervention studies in the cognitive rehabilitation of individuals with traumatic brain injury: Challenges faced by researchers. Neuropsychology Review, 16(4), 151-159.

Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker, M., Moore Sohlberg, M., Yorkston, K., Chiou, H. H., & Kan, P. F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations. Neuropsychological Rehabilitation, 18(3), 257-299.

Kilov, A. M., Togher, L., & Grant, S. (2009). Problem solving with friends: Discourse participation and performance of individuals with and without traumatic brain injury. Aphasiology, 23(5), 584-605.

Lennox, D. B., & Brune, P. (1993). Incidental teaching for training communication in individuals with traumatic brain injury. Brain Injury, 7(5), 449-454.

MacDonald, S., & Wiseman-Hakes, C. (2010). Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive-communication interventions. Brain Injury, 24(3), 486-508.

Mackay, L. E., Bernstein, B. A., Chapman, P. E., Morgan, A. S., & Milazzo, L. S. (1992). Early intervention in severe head injury: Long-term benefits of a formalized program. Arch Phys Med Rehabil, 73(7), 635-641.

McDonald, S., Togher, L., Tate, R., Randall, R., English, T., & Gowland, A. (2013). A randomised controlled trial evaluating a brief intervention for deficits in recognising emotional prosody following severe ABI. Neuropsychological Rehabilitation, 23(2), 267-286.

Moseley, A. M., Herbert, R. D., Sherrington, C., & Maher, C. G. (2002). Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Australian Journal of Physiotherapy, 48(1), 43-49.

Neumann, D., Babbage, D. R., Zupan, B., & Willer, B. (2015). A randomized controlled trial of emotion recognition training after traumatic brain injury. The Journal of Head Trauma Rehabilitation, 30(3), E12-E23.

O’Neil-Pirozzi, T. M., Strangman, G. E., Goldstein, R., Katz, D. I., Savage, C. R., Kelkar, K., Supelana, C., Burke, D., Rauch, S. L., & Glenn, M. B. (2010). A controlled treatment study of internal memory strategies (I-MEMS) following traumatic brain injury. Journal of Head Trauma Rehabilitation, 25(1), 43-51.

Pahisa-Solé, J., & Herrera-Joancomartí, J. (2017). Testing an AAC system that transforms pictograms into natural language with persons with cerebral palsy. Assistive technology : the official journal of RESNA, 1-9.

Perdices, M., Schultz, R., Tate, R., McDonald, S., Togher, L., Savage, S., Winders, K., & Smith, K. (2006). The Evidence Base of Neuropsychological Rehabilitation in Acquired Brain Impairment (ABI): How Good is the Research? Brain Impairment, 7(02), 119-132.

Radice-Neumann, D., Zupan, B., Tomita, M., & Willer, B. (2009). Training emotional processing in persons with brain injury. Journal of Head Trauma Rehabilitation, 24(5), 313-323.

Rajaram, P., Alant, E., & Dada, S. (2012). Application of the self-generation effect to the learning of blissymbols by persons presenting with a severe aphasia. AAC: Augmentative and Alternative Communication, 28(2), 64-73.

Ripich, D. N., Ziol, E., Fritsch, T., & Durand, E. J. (1999). Training Alzheimer’s disease caregivers for successful communication. Clinical Gerontologist, 21(1), 37-56.

Sarno, M. T., Buonaguro, A., & Levita, E. (1986). Characteristics of verbal impairment in closed head injured patients. Arch Phys Med Rehabil, 67(6), 400-405.

Sigafoos, J., & Drasgow, E. (2001). Conditional Use of Aided and Unaided AAC: A Review and Clinical Case Demonstration. Focus on Autism and Other Developmental Disabilities, 16(3), 152-161.

Sim, P., Power, E., & Togher, L. (2013). Describing conversations between individuals with traumatic brain injury (TBI) and communication partners following communication partner training: Using exchange structure analysis. Brain Inj, 27(6), 717-742.

Story, T. B. (1991). Cognitive rehabilitation services in home and community settings. In J. S. K. P. H. Wehman (Ed.), Cognitive rehabilitation for persons with traumatic brain injury: A functional approach (pp. 251-267). Baltimore, MD, England: Paul H. Brookes Publishing.

Strauss HM, & RS, P. (1994). Pragmatics and treatment. . In Chapey R (Ed.), Language Intervention Strategies in Adult Aphasia. (pp. 246-268). Baltimore: Williams & Wilkins.

Struchen, M. (2005). Social communication interventions. In High W, Sander A, & H. K. (Eds.), Rehabilitation for traumatic brain injury (pp. 88-117). New York, NY: Oxford University Press.

Sumowski, J. F., Coyne, J., Cohen, A., & Deluca, J. (2014). Retrieval practice improves memory in survivors of severe traumatic brain injury. Arch Phys Med Rehabil, 95(2), 397-400.

Togher, L., McDonald, S., Code, C., & Grant, S. (2004). Training communication partners of people with traumatic brain injury: A randomised controlled trial. Aphasiology, 18(4), 313-335.

Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk, R. (2013). Training communication partners of people with severe traumatic brain injury improves everyday conversations: a multicenter single blind clinical trial. J Rehabil Med, 45(7), 637-645.

Togher, L., McDonald, S., Tate, R., Rietdijk, R., & Power, E. (2016). The effectiveness of social communication partner training for adults with severe chronic TBI and their families using a measure of perceived communication ability. NeuroRehabilitation, 38(3), 243-255.

Turkstra, L. S. (1998). The effect of stimulus presentation rate on syntax test performance in brain-injured adolescents. Aphasiology, 12(6), 421-433.

Westerhof-Evers, H. J., Visser-Keizer, A. C., Fasotti, L., Schonherr, M. C., Vink, M., van der Naalt, J., & Spikman, J. M. (2017). Effectiveness of a Treatment for Impairments in Social Cognition and Emotion Regulation (T-ScEmo) After Traumatic Brain Injury: A Randomized Controlled Trial. J Head Trauma Rehabil, 32(5), 296-307.

Wielaert, S. M., Sage, K., Heijenbrok-Kal, M. H., & Van De Sandt-Koenderman, M. W. M. E. (2016). Candidacy for conversation partner training in aphasia: findings from a Dutch implementation study. Aphasiology, 30(6), 699-718.

Wiseman-Hakes, C., MacDonald, S., & Keightley, M. (2010). Perspectives on evidence based practice in ABI rehabilitation. “relevant Research”: Who decides? NeuroRehabilitation, 26(4), 355-368.

Wiseman-Hakes, C., Stewart, M. L., Wasserman, R., & Schuller, R. (1998). Peer group training of pragmatic skills in adolescents with acquired brain injury. J Head Trauma Rehabil, 13(6), 23-36.

World Health Organization. (2001). International Classification of Functioning, Disability and Health.

Ylvisaker M, & SF, S. (1994). Communication Disorders Associated with Closed Head Injury. In C. R. (Ed.), Language Intervention Strategies in Adult Aphasia. (book) (pp. 546-568). Baltimore: MD: Williams & Wilkins.

Ylvisaker, M. S., & Urbanczyk, B. (1990). The efficacy of speech-language pathology intervention: Traumatic brain injury. Semin Speech Lang, 11(4), 215-226.