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COGNITIVE COMMUNICATION DISORDERS IN ADULTS WITH ACQUIRED BRAIN INJURY: CURRENT PERSPECTIVES

Kara Kozub O’Dell, M.A. CCC-SLP, BISAllied Health Manager, Patient Recovery UnitThe Rehabilitation Institute of Chicago

COGNITION

The process of knowing

Knowledge of thoughts, feelings, & ideas

The process that is used to understand & interact with the world

Used to describe how our brain functions to perceive & express experiences

COMMUNICATION

Any means by which an individual relates experiences, ideas, knowledge and feelings to another

Results from a complex interaction between cognition, language and speech

Language

Speech

Cognition

COGNITIVE-COMMUNICATION DISORDERS

Cognitive-communication disorders encompass difficulty with any aspect of communication that is affected by disruption of cognition. Areas of function affected by cognitive impairments include behavioral self regulation, social interaction, activities of daily living, learning and academic and vocation performance.

(ASHA, 2004)

COGNITIVE-COMMUNICATION DISORDERS

Decreased ADL and IADL function

Poor physical function

Require longer term rehabilitation

Greater expenditure of healthcare resources

(Zinn, 2004)

ACQUIRED BRAIN INJURY

Brain Injury Association of America:-- An injury to the brain, which is not hereditary, congenital,

degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth Traumatic Brain Injury Stroke Hypoxic or Anoxic Brain Injury Tumor Substance Abuse Illness

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PREVALENCE

1.7 people sustain a new traumatic brain injury each year

Approximately 75% are concussions or mild TBIs

Every year, more than 795,000 people in the United States have a stroke

(Faul, 2010)

(Roger, 2012)

COGNITIVE COMMUNICATION DEFICITS AFTER ABI

As many as two-thirds of patients experience cognitive impairment or decline following ABI

Cognitive rehabilitation serves to:

1) reinforce, strengthen or re-establish previously learned patterns of behavior

2) establish new patterns of cognitive activity through compensatory cognitive mechanisms for impaired neurological systems

3) establish new patterns of activity through external compensatory mechanisms such as environmental structuring and support

4) enable persons to adapt to their cognitive disability(Zinn, 2004)

COGNITIVE DOMAINS

Awareness

Attention

Memory

Problem Solving

Pragmatics

Executive Functions

CLINICAL DECISION PROCESSES: EVIDENCE BASED PRACTICE (Sackett, et al, 2000)

BEST CURRENT EVIDENCE

CLIENT VALUES

CLINICAL EXPERTISE

ICF FRAMEWORK

Internal Classification of Functioning, Disability, and Health (ICF) Framework Implementation in 2001 with unanimous endorsement of

the classification by the 54th World Health Assembly

Framework for describing and measuring health and disability

Used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement in clinical setting

ICF FRAMEWORK: DEFINITIONS

Impairments: problems in body function or structure such as a significant deviation or loss.

Activity: the execution of a task or action by an individual.

Participation: involvement in a life situation. Activity Limitations: difficulties an individual may have in

executing activities. Participation Restrictions: problems an individual may

experience in involvement in life situations. Environmental Factors: make up the physical, social and

attitudinal environment in which people live and conduct their lives.

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“EVALUATION” or “ASSESSMENT”

Merriam-Webster, 2012 Evaluation: “to determine the significance, worth, or

condition of, usually by careful appraisal and study”

Assessment: judgment based on understanding of a situation

Evaluation is the process, while assessment is the result

WHO CLASSIFICATION:IMPLICATIONS FOR ASSESSMENT

Impairment

Activity/Participation

Environmental Factors

Standardized tests to ID underlying neuropsychological and neurolinguistic strengths

Standardized or nonstandardized observation of individual performing functional activities and exploration of factors that influence performance such as possible compensatory strategies

Systematic documentation of environmental factors, including support of behaviors of communication partners

(Turkstra, et al, 2005)

WHO Category Assessment Tool and Procedures

FRAMEWORK

Plan, Implement, and Evaluate Basis for designing and implementing various

interventions

Planning the therapy for optimal success

Implementation refers to methods utilized within the session that impact outcomes

Evaluation of client performance

(Sohlberg and Turkstra, 2011)

FRAMEWORK: PLAN

Identify key learner characteristics Cognitive linguistic functions, physical abilities, sensory

abilities, psychological status, social connections

Define the training target

State the desired outcome

Design individual training plan

(Sohlberg and Tursktra, 2011)

ANCDS PRACTICE OPTIONS

Based on detailed review of test manuals, published studies and experts’ published opinions

Define purpose of assessment Design specific intervention

Create a support plan

Monitor progress towards objectives


ASSESSEMENT / PLAN

ANCDS Guidelines (www.ancds.duq.edu)

Internal consistency

Test-retest reliability

Construct validity

Concurrent validity

Predictive validity

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ASSESSEMENT / PLAN

ANCDS Practice Options

1. Take caution in using published, standardized, norm-referenced tests

2. The committee identified several tests that met a majority of the stated criteria for reliability and validity

3. Consider standardized testing with a broader framework, including assessment of pre-injury characteristics, stage of recovery and communication related demands of everyday activities

4. Integrate cognitive assessments with other professionals whose scope of practice includes cognitive assessment (i.e. OT, neuropsychology)


ASSESSEMENT / PLAN

Self-report / Self-assessment

Jamora, Young and Ruff, 2011: Mild TBI: Self reported attention problems predicted

performance on neuropsychological attention and concentration measures

Moderate to severe TBI: Self reported memory problems predicted performance on neuropsychological measures of memory and learning

TREATMENT EFFICACY SUMMARY

Traumatic Brain Injury Attention (82%) Memory (81%) Pragmatics (83%) Problem Solving (80%)

Right Hemisphere Dysfunction: Attention (80%) Memory (74%) Problem Solving (73%) Pragmatics (77%)

(ASHA NOMS)

WHAT INFLUENCES LEARNING

Personal Characteristics

Environmental Factors

Program Characteristics


LEARNING: PERSONAL CHARACTERISTICS

Self efficacy

Locus of control

Therapy program beliefs and expectations

Disease characteristics

Cognitive status

Psychosocial status

LEARNING: ENVIRONMENTAL FACTORS

Facilities

Social and cultural influences

Collaboration

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LEARNING: PROGRAM CHARACTERISTICS

Intensity Timing of intervention Task complexity Practice conditions Cueing and feedback Maintenance and generalization Therapeutic relationships Supervision/accountability Use of technology

INSTRUCTIONAL METHODS

Do SLPs need instruction on instruction? Systematic Instructional ApproachMethod of Vanishing Cues, Spaced Retrieval

Conventional Methods Trial-and-Error Approach, Test and Correct

FRAMEWORK: IMPLEMENTATION

Initial Acquisition

Mastery and Generalization

Maintenance


FRAMEWORK: IMPLEMENTATION

During each phase of training, consider: Level of error control

Type of practice

Intensity and dose of practice

IMPLEMENTATION: ERROR CONTROL

Systematic Approach: Errorless learning (EL) Eliminate errors by providing models before the client

attempts a response

Guessing is discouraged(Baddeley & Wilson, 1994)

Conventional Approach: Errorful or Trial and Error Learning “Teaching” versus “testing”

IMPLEMENTATION: ERROR CONTROL

Growing evidence to support EL, particularly during acquisition phase Lloyd, Riley & Powell, 2009

Campbell, et al, 2007

Bowman, et al, 2010

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IMPLEMENTATION: TYPE OF PRACTICE

How is a fixed amount of practice distributed over time? Massed Less time between practice trials or sessions

DistributedMore time between practice trials or sessions

(Mass, et al, 2008)

IMPLEMENTATION: PRACTICE SCHEDULE

Practice Schedule Random Different tasks/targets are produced on successive trials and

target is not predictable to client for upcoming trials

Blocked Client practices same tasks/targets before beginning practice

on next tasks/targets

(Mass, et al, 2008)

IMPLEMENTATION: INTENSITY AND DOSE

How hard is client working?

How many sessions and for what length of time?

IMPLEMENTATION ACROSS THE PHASES

Acquisition Errorless learning Massed, high repetition, blocked practice

Mastery and Generalization Error control, feedback Distributed practice over longer periods of time

Maintenance Trial and error, feedback Introduction of strategies “Booster” session

(Sohlberg & Turkstra, 2011)

IMPLEMENTATION: EVIDENCE BASED PRACTICE

Identify and translate best research evidence

In the absence of evidence: Design treatment based on theories of underlying

deficit

Base treatments on deficits rather than etiology

(Blake, 2007)

THEORIES OF UNDERLYING DEFICITS: AN EXAMPLE

COGNITIVE RESOURCES HYPOTHESIS Amount of cognitive effort affects performance

after brain damage Cognitive resources contribute to language abilities

on the complex end of the continuum Should be considered with hypotheses for specific

abilities Suggests complexity of tasks and stimuli should be

carefully considered(Monetta, Ouellet-Plamodon & Joanette, 2003)

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COGNITIVE RESOURCES HYPOTHESIS

IMPLEMENTATION ACROSS THE PHASES- - Acquisition

Errorless learning Massed, high repetition, blocked practice

Mastery and Generalization Error control, feedback Distributed practice over longer periods of time

Maintenance Trial and error, feedback Introduction of strategies “Booster” session

(Sohlberg & Turkstra, 2011

FRAMEWORK: EVALUATION OF OUTCOME

Session data

Generalization probes

Maintenance probes

Impact data

Efficacy data

Uses of clinical data


MEMORY DEFINED

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Reflects our experience of the past

Allows us to adapt to the present

Allows us to look forward to the future

Critical to the acquisition and utilization of new information

Important brain areas for memory function:

Amygdala & Hippocampus

COMPONENTS OF MEMORY

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Sensory Memory Initial processing of information following registration by the

sensory organs

Short Term or Working Memory Temporary storage of information in use Recent memory

Long Term Memory Permanent storage of information Declarative vs. procedural

(Halper, Cherney & Miller, 1991)

OPERATIONS OF MEMORY

Encoding Set of processes by which the representation of an event is formed

and constructed

Two stages Holding

Acquiring

Storage Process of transferring a transient memory into permanent storage

Retrieval Involves the activation of the memory traces in the permanent

memory so they are available for use

LEARNING AND MEMORY DEFICITS: EVIDENCE BASED PRACTICE

WHAT WORKS? External Strategy Use

Internal Strategy Use

Memory Programs

WHAT DOESN’T WORK? Cranial electrotherapy stimulation

Computer assisted training

VR Programs

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EXTERNAL AIDS

RCTs: Calendar use

Paper: Diaries, memory notebooks, log books, “to do” lists

Paging systems

Hand held recorders

PDAs and smart phones

EXTERNAL AIDS

Memory, attention and executive functions Evidence to support use of technology and external

aids to improve life participation for individuals with cognitive impairments

Indicators for successful device use: Device selection Age Severity Specificity of deficit Premorbid functioning

EXTERNAL AIDS: PLAN/ASSESSMENT

Matching Person and Technology Assessment www.matchingpersonandtechnology.com/index.html

Contains a series of instruments: Self report checklists

Environments in which the client will use technology

Individual characteristics and preferences

Technology’s features and functions

Technology specific forms Assistive Technology Device Predisposition Assessment (ATD PA)

Educational Technology Predisposition Assessment (ET PA)

The Workplace Technology Predisposition Assessment (WT PA)

The Health Care Technology Predisposition Assessment (HCT PA)


Matching Person and Technology Assessment Process Assesses limitations, strengths, goals and potential

interventions in conjunction with: Body functions

Activities

Screen or complete assessment


Matching Person and Technology Process: User goals and preferences drive the MPT process Providers are guided into considering all relevant influences

on the use of a technology while focusing on the user's life participation

Mismatches between a proposed technology and a potential user are identified

The most appropriate technology is selected when there is a choice of several

Appropriate training strategies are identified for an individual's optimal use of a technology

(Scherer, et al, 2007)


TechMatch www.coglink.com/techmatch Computer survey Goal: Assist healthcare providers in matching people

with cognitive deficits to computer tools that will help with life participation

Assessment: Technology experience and abilities Environment User needs Cognitive ability Personal situation

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INTERNAL STRATEGY USE

RCTs: Visual imagery

Verbal labeling / elaboration

Mnemonics

INTERNAL AIDS: PLAN/ASSESSMENT

Consider personal learning characteristics

Consider environmental learning factors

Saliency matters

User goals and preferences should drive the selection process

MEMORY AIDS: IMPLEMENTATION

Acquisition Establish motivation and procedures for using aid Client involved in selection of aid

Systematic instruction of procedures

Relevant training examples

Error control

Fade cues

Intensive massed practice initially

Distribute practice once steps are learned

MEMORY AIDS: IMPLEMENTATION

Mastery and generalization Strengthen use

Broaden contexts

Lengthen distributed practice

Correct errors, repeat practice before further fading cues

Provide opportunities to use aid

Maintenance Schedule follow up sessions

MEMORY AIDS: EVALUATE OUTCOMES

Frequency of use

Self-report or ratings of satisfaction and life participation

Performance on tasks in which aid is to be utilized

MEMORY RE-TRAINING PROGRAMS: THE EVIDENCE

Memory-retraining programs appear effective, particularly for functional recovery although performance on specific tests of memory may or may not change

Although several mnemonic strategies have been used to help improve memory post ABI, retrieval practice seems to be the most effective

Recall and recognition of words can be enhanced by using a spaced learning condition

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MEMORY RE-TRAINING PROGRAMS

Error Control

Method of Vanishing Cues

Spaced Retrieval

MEMORY RE-TRAINING: ERROR CONTROL

Research supports errorless learning for individuals with moderate to severe impaired explicit memory

Trial and error learning may be indicated Update knowledge of performance based on

feedback

Ability to monitor and detect errors

(Clare & Jones, 2008)

METHOD OF VANISHING CUES

Error controlled Systematically reduce cues until target is acquired Client is discouraged from using strategies or guessing If client gives incorrect response, clinician returns to

level that client is successful at and begins again Learning proceeds until there are no visible cues, then

distractors are introduced systematically until the target can be expressed in functional contexts

(Sohlberg & Turkstra, 2011)


Example: Teaching a client your or another staff member’s name

MARIA


MARI_


MAR_ _

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MA_ _ _

SPACED RETRIEVAL

Error controlled Expanded rehearsal Form of MVC – systematic approach Add increased time intervals between opportunities for

practice Start with 30 seconds and double intervals until an

upper limit is reached or the client makes an error If client makes an error, model correct target and return

to last successful time interval Response is considered learned after the client can

produce it the next day(Brush & Camp, 1998)

INTERVENTION: MEMORY

Systematic Approach: Implicit or Procedural Memory

Declarative Memory

Strategy Use: High Declarative Memory or Executive Function Demands

Training techniques vary based on declarative memory and executive functions

INTERVENTION: MEMORY

Evidence based practice:

Implicit learning techniques: for clients with severe memory impairments, systematic, error control methods with spaced retrieval are most effective

Declarative learning techniques: for clients with mild to moderate impairments, internal strategies may be most effective

ATTENTION

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The ability to focus on certain aspects of the environment that one considers important or interesting & to flexibly manipulate this information. Prerequisites to attention are alertness & arousal.

(Sohlberg & Mateer, 1987)

ATTENTION: EVIDENCE BASED TREATMENT

Specific structured training programs are ineffective(Cicerone, et al, 2005, 2011)

Dual Task Training and Reaction Time Individuals with ABI perform poorly on dual task

activities Individuals with ABI have slower reaction times than

individuals without(Couillet et al, 2010)

(Azoui et al, 2004)

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ATTENTION HIERARCHY

Arousal / Alertness

Focused Attention

Sustained Attention

Selective Attention

Alternating Attention

Divided Attention

DUAL TASK TRAINING FOR ATTENTION

Train 2 sustained attention tasks separately then combine Walking and having a conversation

Listening while taking notes

Texting while having a conversation

Watching TV while talking on the phone


Cognitive-motor interference (CMI) Simultaneous performance of cognitive and motor task

interferes with one or both tasks

Demands for attention resources compete(Woollacott & Shumway-Cook, 2002)


Couillet et al, 2010 12 patients with TBI in subacute/chronic phases

6 weeks - - 4 sessions, each1 hour in length

Experimental group trained first on single tasks, then dual tasks of progressing difficulty

Outcome measures included attentional tests, executive and working memory tests and dual-task measures

Significant training related effect on divided attention


Positive effect on divided attention

Effective on the speed of processing

Assists individuals in dealing with dual task situations rapidly and accurately

TIME PRESSURE MANAGEMENT

Increase awareness of errors and relation to slow processing

Compensation for slowed information processing through anticipation and self management

Reduce experience of ‘information overload’ in daily tasks

(Fasotti et al, 2000)

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Increased use of self-management strategies (interrupting, repeating essential information) after TPM

Improvements apparent on more complex tasks, but not basic reaction time

(Fasotti et al, 2000)


Stage1: Identify the problem

Stage 2: Teach the strategy

Stage 3: Generalization

(Winkins et al, 2009)


Strategies: Priority is always- - “Let me give myself enough time to

complete the task” Therapist introduces strategies and provides example /

talks the patient through using a simple task (i.e. preparing a meal)

Specifics strategies are: analyzing time pressure preventing time pressure handling time pressure monitoring task performance


1. Analyze task for time pressures and determine where strategies may help (“Are there 2 or more things to be done at the same time?” “Might I become overwhelmed or distracted?”)

2. Determine which decisions or actions can be performed before actually starting the activity

3. Make a plan for anything unexpected that may occur (list and create plans for possible scenarios)

4. Learn to monitor performance

(Winkins et al, 2009)

TPM: COOKING A MEAL

1. WHAT ARE TIME PRESSURES? WHICH STRATEGIES MAY HELP? Cutting and preparing ingredients while reading a recipe

and watching for water to boil; plan and sequence steps prior to beginning

2. WHAT CAN BE DONE AHEAD OF TIME? Read the recipe, cut vegetables and measure out ingredients

3. WHAT UNEXPECTED COULD OCCUR? Phone could ring; let it go

4. EVALUATE PERFORMANCE Did I complete the task? What went well? What did not?

EXECUTIVE FUNCTIONS

John gets up off of the couch and heads to the kitchen, where he forgets why he even headed there in the first place!

Katie starts to clean her apartment when she sees an unpaid bill sitting on her table. She promptly pays her bill and then sits down to watch her favorite TV show. When her sister shows up later that evening and comments on how dusty the apartment is, Katie realizes that she never finished cleaning.

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EXECUTIVE FUNCTIONS

Mary went to the grocery store to get the items to make spaghetti for friends coming to dinner that evening. After picking up the items for a salad, she ran into a friend from high school. They talked for almost 15 minutes before Mary went to the checkout and paid for her items. When Mary got home about an hour before her friends were to arrive, she realized that she did not get all of the items on her list.

EXECUTIVE FUNCTIONS

The direction and organization of all cognitive and emotional processes in order to attain goals and regulate behavior that is consistent with attaining such goals Includes setting realistic goals based on accurate self appraisal,

monitoring your behavior and evaluating your performance in relation to these goals, problem solving and changing behavior to come about obtaining the best solutions

A set of cognitive abilities that control and regulate other abilities and behaviors; executive functions are necessary for goal directed behavior

(Ready, et al. 2001)

A CLINICAL MODEL OF EXECUTIVE FUNCTIONS

Initiation and drive (Starting behavior) Response inhibition (Stopping behavior) Task persistence (Maintaining behavior) Organization (Organizing thoughts and actions) Generative thinking (Creativity, fluency, flexibility) Awareness (Monitoring and modifying one’s own

behavior)

(Sohlberg & Mateer, 2001)

A FUNCTIONAL MODEL OF EXECUTIVE FUNCTIONS

Grocery Shopping Does not initiate going to the store even when refrigerator

is empty Impulsive shopping, buys unnecessary items Does not maintain focus and does not get all items Does not organize a grocery list, use aisle headings or use

time efficiently when gathering groceries Lacks flexibility to substitute appropriate items if desired

items are unavailable Is not aware that getting groceries is a concern

EXECUTIVE FUNCTIONS: EVIDENCE BASED TREATMENT

WHAT MAY WORK? Group Treatment

Pharmacological Intervention

Goal Management Training

Teach-M

FURTHER RESEARCH IS NEEDED!

EXECUTIVE FUNCTIONS: EVIDENCE BASED TREATMENT

There is conflicting evidence as to whether or not group therapy for executive functions is effective Novakovic-Agopian et al, 2011

Ownsworth et al, 2008

Pharmacological interventions Evidence to support use of amantadine

Evidence with bromocriptine is inconclusive

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GOAL MANAGEMENT TRAINING

Duncan’s Theory of Disorganization (1986)Goal management deficits or “goal neglect”

Goal Management TrainingPrimary Objective: Train patients to stop ongoing

behavior in order to define goal hierarchies and monitor performance

5 stages

(Robertson, 1996)

GOAL MANAGEMENT TRAINING

1. “Stop. What am I doing?”

2. “Define the goal”

3. “List the steps”

4. “Learn the steps”

5. “Check. Am I doing what I planned?”

(Robertson, 1996)

TEACH-M

Framework for teaching new, multistep skills to patients with impaired memory and executive functions

Derived from current research on instructional techniques

Combines instructional techniques into a protocol for teaching specific tasks to individuals with ABI

(Ehlhardt, et al, 2005)

TEACH-M

Task Analysis

Errorless Learning

Assessment

Cumulative Review

High Rates of Correct Practice

Metacognitive Strategy

TEACH-M

Task Analysis Know the instructional content, break it up into small

steps, chain steps together

Errorless Learning Error control

Assessment Assess skills prior to initiating intervention, probe

performance at start of each session or prior to teaching new step

TEACH-M

Cumulative Review Regularly integrate and review new skills with

previously learned skills

High Rates of Correct Practice Practice skills, consider distributed practice

Metacognitive Strategy Encourage self-reflection and problem solving

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TEACH-M

Initial Probe Probe- Can patient perform all components of the target task?

Task-Analysis, Errorless Learning, High Rates of Practice and Assessment Therapist analyzes task and breaks it into steps

Therapist models each step multiple times

Patient practices each step multiple times, while therapist fades cues (errorless learning)

High amounts of isolated, blocked practice for any steps that are problematic

Probe at the start of each session for retention from previous session

TEACH-M

Metacognitive Strategy Training Patient is asked to reflect on steps he/she has learned and predict which

may be difficult during review phase

Cumulative Review (Including spaced-retrieval practice) Increase consolidation and retention of new information by using spaced

retrieval practice to have patient recall steps to complete task over time

Metacognitive Strategy Training – Part 2 Patient completes task and compares actual performance to predicted

performance

CONCLUSIONS

Best practice for assessing and managing cognitive communication deficits after ABI, means considering: What we should assess (ICF framework) and how we

should assess it (ANCDS Practice Options)

Personal, environmental and program characteristics

Instructional techniques best suited to person, cognitive domain and phase of implementation

REFERENCES

Baddeley A & Wilson BA (1994). When implicit learning fails: Amnesia and the problem of error elimination. Neuropsychologia, 32(1), 53-68.

Brush JA & Camp CJ (1998). A therapy technique for improving memory: Spaced retrieval. Beachwood, OH: Menorah Park Center for the Aging.

Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S. et al. (2005). Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002. Arch.Phys.Med.Rehabil, 86,1681-1692.

Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M. et al. (2011). Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch.Phys.Med.Rehabil., 92, 519-530.

Clare L & Jones R (2008). Errorless learning in the rehabilitation of memory impairment: a critical review. Neuropsychol Rev. 18: 1-23.

Couillet J, et al (2010). Rehabilitation of divided attention after severe traumatic brain injury: a randomised trial. Neuropsy Rehabil. 20(3).

Ehlhardt LA, Sohlberg MM, Glang A & Albin R (2005). TEACH-M: A pilot study evaluating instructional sequence for persons with impaired memory and executive functions. Brain Inj. 19:569-583.

Ehlhardt LA, Sohlberg MM, Kennedy M, Coelho C, Ylvisaker M, Turkstra L & Yorkston K (2008). Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years? Neuropsy Rehabil. 18:300-42.

REFERENCES

Fasotti L, Kovacs F, Eling PATM & Brouwer WH (2000). Time pressure management as a compensatory strategy after closed head injury. Neuropsyc Rehabil, 10(1), 47-65.

Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

Jamora CW, Young A, Ruff RM (2012). Comparison of subjective cognitive complaints with neuropsychological tests in individuals with mild vs more severe traumatic brain injuries. Brain Inj. 26(1):36-47.

Maas E, et al. (2008). Principles of motor learning in treatment of motor speech disorders. Amer Jour Speech Lang Pathol. 17: 277-298.

Monetta L & Joanette Y (2003). Specificity of the right hemisphere’s contribution to verbal communication: The cognitive resource hypothesis. Journal of Speech Lang Path, 11, 203-11.

Ready, R., Stierman, L. & Paulsen, J. (2001). Ecological Validity of Neuropsychological and Personality Measures of Executive Functions. The Clinical Neurophysiologist, 15:3, 314-323.

Robertson, IH (1996). Goal Management Training: A clinical manual. Cambridge, U.K.: PsyConsult.

Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al (2012). Heart disease and stroke statistics- 2012 updates: a report from the American Heart Association. Circulation.125(1):e2–220.

Scherer et al. (2007). Assistive technologies for cognitive disabilities. Critical Rev in Phys Med and Rehabil. 17, 195-215.

REFERENCES

Sohlberg M & Mateer C (2001). Cognitive rehabilitation: an integrative neuropsychological approach. New York: Guilford.

Sohlberg M & Turkstra L (2011). Optimizing cognitive rehabiliation: effective instructional methods. New York: Guilford.

Turkstra L et al (2005). Practice guidelines for standardized assessment for persons with traumatic brain injury. Jour of Med Speech Pathol, 13:2, ix-xxvii.

Winkens I, Van Heugten CM, Wade DT, Fasotti L (2009). Training Patients in Time Pressure Management, a cognitive strategy for mental slowness. Clin Rehabil,23(1): 79-90.

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

Woollacott M, Shumway-Cook A. Attention and the control of posture and gait: a review of an emerging area of research. Gait Posture. 2002;16:1–14.

Zinn S, Dudley TK, Bosworth HB, Hoenig HM, Duncan PW, Horner RD (2004). The effect of poststroke cognitive impairment on rehabilitation process and functional outcome. Archives Phys Med and Rehabil. 85:1084-1090.

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