Cognitive-Linguistic Rehabilitation in mtbi: Is There a Scientific Basis?

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1 Cognitive-Linguistic Rehabilitation in mtbi: Is There a Scientific Basis? Bruce E. Murdoch, PhD DSc Motor Speech Research Centre School of Health & Rehabilitation Sciences The University of Queensland

2 Background Communicative competence involves a complex interaction of sensory awareness and perception, concentration, cognitive and linguistic processes, sensitivity to context, social perception and other executive skills (e.g. planning, organization, initiation and self-monitoring TBI can result in disorders of all of these factors inextricably involved in effective communication Contemporary research investigating the behavioural sequelae associated with TBI has largely focussed upon individuals with moderate to severe trauma

3 Background Within this corpus of data, the nature of cognitivelinguistic compromise resulting from diffuse brain injury has been difficult to capture One reason is that language disorders resulting from diffuse neuropathology associated with TBI are qualitatively different from those associated with focal brain damage not detectable by standard language tests devised for latter group

4 Background Individuals with TBI rarely present with aphasia and usually perform well on tests of primary language function However, TBI associated with debilitating difficulties in communicative activities in daily living Communication difficulties in TBI consequently rarely considered to be result of specific linguistic deficits Rather, they are considered manifestations of impairments in broad-ranging cognitive and executive functions which support language

5 Background Currently language and cognition viewed as interrelated elements of language and cognition viewed as integral components within a reciprocal relationship Provide a global framework to conceptualize communicative disorders in TBI potentially enables all factors contributing to communicative breakdown to be explored Essential language in TBI examined from this global framework with balance of cognitive and linguistic elements Unfortunately most previous research into language in TBI and especially mtbi has inadequately assessed the linguistic component

6 Background While standardized measures of language denounced as insensitive to deficits in TBI, likely selected tests insufficient and incomplete Even in more recent TBI research language measures used to determine presence and severity of linguistic disorders limited to basic tests of aphasia or subtests of neuropsychological test batteries lack of in-depth linguistic analysis Above tests designed to assess primary language skills (focal brain injury) but fail to examine language comprehensively on more complex tasks (especially those dependent on intact frontal lobe function) Understandable therefore why such tests fail to identify the nature of language impairment in TBI

7 Background Administration of tests of higher-order linguistic function demanding frontal lobe support have provided the best insight into language disorders associated with TBI Lexical-semantic access and manipulation, complex auditory comprehension and attentional deficits identified as cardinal cognitive-linguistic impairments following SEVERE TBI (Hinchliffe, Murdoch et al., 1998)

8 Background Cognitive deficits resulting from mtbi typically considered transient in nature A subset of individuals, however, experience persistent cognitive symptoms documented up to 3 years postinjury Argues against notion that effects of mtbi for all individuals temporary and that residual deficits disappear spontaneously Non-linguistic cognitive sequelae include reduced processing speed, concentration, attention and memory Given the inter-relationship between language and cognition and the presence of persistent cognitive sequelae, also indicates potential for persistent higherorder linguistic deficits in mtbi

9 Background To answer question: Is there a scientific basis for cognitivelinguistic rehabilitation in mtbi? need to consider several factors: 1. What evidence is there for existence of cognitivelinguistic impairments in mtbi? If present, what aspects of language are affected? 2. What treatments have been applied? What are the findings of any reported treatment studies?

10 Evidence for Cognitive- Linguistic Impairment in mtbi

11 Cognitive-Linguistic Impairment in mtbi Communicative competence of mtbi population largely unknown Majority of research neuropsychologically-based lacking in-depth linguistic analysis (Duff et al., 2002) Deficits in verbal fluency, story recall /verbal memory and anomaly detection reported post-mtbi (Anderson et al., 2001; Goldstein et al., 2001; Hanten et al., 2004) suggests high-level linguistic processes implicated following mtbi Potential high-level language deficits in mtbi also supported by neuroanatomical evidence

12 Cognitive-Linguistic Impairment in mtbi NEUROANATOMICAL SUPPORT Neurological consequences of TBI = multifarious and complex, potentially occurring throughout entire neural axis Diffuse cerebral injury involving widespread axonal damage considered primary mechanism of TBI with superimposed focal damage to frontal and temporal lobes [given proximity to bony protrusions and cavities] Specific brain regions reportedly more vulnerable to axonal shearing/ stretching including subcortical white matter, upper brain stem, superior cerebellar peduncles and basal ganglia Resultant behavioural deficits therefore speak to network models of language processing involving the interplay of cortical and subcortical systems

13 Cognitive-Linguistic Impairment in mtbi NEUROANATOMICAL SUPPORT Although based on conventional neuroimaging brain may appear structurally normal, TBI of any severity compromise of multiple, interrelated physiological components that exert 1 st and 2 nd effects at level of individual neurones and connected networks of neurones Possible mechanisms of mtbi include: Chemical changes to molecules of metabolism Adverse cellular responses to injury Alterations to neurotransmission systems Dynamic imaging studies involving cerebral perfusion and metabolism have demonstrated frontal and temporal lobe abnormalities in mtbi In terms of localization theory these findings have evident implications for language function

14 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Consistent with the high-level language hypothesis deficits in lexical access, complex lexical-semantic manipulation at single word and sentential levels, plus the organization and monitoring of responses identified in single case, 2 years post-injury (Whelan & Murdoch, 2007) Preliminary findings of larger study currently in progress aimed at highlighting cognitive-linguistic domains sensitive to mtbi supportive of above details provided subsequent slides

15 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Methods: Subjects 5 subjects (3 male, 2 female) with TBI. Mean age 53 (range 19-67) Criteria for mtbi defined by Kay et al. (1993) LOC less than 30 minutes GCS of following LOC Period of post-traumatic amnesia less than 24 hours All subjects at least 6 months post-injury (range 6-18 months) MRI / CT scans available for 4 subjects all normal

16 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Methods: Subjects 5 non-neurologically impaired adults, matched for age, gender and level of education, served as controls Standard inclusion criteria: English as first language No previous history of neurological injury/disease No history of substance abuse No history of speech/ language disorder Right handed

17 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Methods: Assessment Battery Cognition Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI): assessment of cognitive domains of perception, discrimination, organization, information recall and problem solving General Language Neurosensory Centre Comprehensive Examination of Aphasia (NCCEA) Boston Naming Test (BNT)

18 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Methods: Assessment Battery High-Level Language Test of Language Competence-Expanded (TLC-E): assessment of language proficiency and metalinguistic ability, probing semantic system, semantic-syntactic interfaces and pragmatics The Word Test-Revised (TWT-R): assessment of expressive vocab and semantics Wiig-Semel Test of Linguistic Concepts (WSTLC): assessment of comprehension of complex linguistic structures

19 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Results: Cognition mtbi group demonstrated reduced performance on the Perception / Discrimination subtest of the SCATBI Test involves word recognition/auditory tracking tasks in both distracting and non-distracting conditions Results suggestive of mild attentional disturbance

20 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Results: General Language Performance of mtbi comparable to controls for all NCCEA subtests and BNT No general language deficits identified at group level

21 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Results: High-Level Language mtbi group performed significantly below controls on the following: TLC-E Recreating sentences subtests TWT-R Semantic absurdities Multiple definitions WSTLC Passive and temporal subtests

22 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Findings provide support for hypothesis of cognitivelinguistic compromise as consequence of mtbi 1. Cognitive Profile Reduced score on Perception/ Discrimination subtest of SCATBI Word recognition/ auditory tracking tasks with an without distraction? General cognitive profile = mild attentional disturbances

23 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Selective impairment of attention and information processing abilities as consequence of mtbi well described in literature (Gronwall et al., 1974; Gronwall et al., 1981; Hugenholtz et al., 1988; MacFlynn et al., 1984; Beers, 1992; Parker, 1996) Impaired attention and information processing skills hypothesised to have adverse effect on performance in vocations that demand decision making and/or stress (Hugenholtz et al., 1988) Consequently mtbi may limit success in vocations contingent upon ability to attend and process for meaning, complex linguistic information

24 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion 2. Linguistic Profile General Language Normal performance of mtbi group on tests of general language abilities consistent with previous TBI reports

25 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion: Linguistic Profile Higher-Level: TLC-E, TWT-R, WSTLC Deficits revealed in number of areas involving complex lexical semantic operations: Sentence construction, multiple definition formulation, absurdity detection/ correction, passive/ temporal structure comprehension, etc These tasks demand frontal lobe support in handling of novel situations, lexical-semantic manipulation, development of language strategies and organisation and monitoring of responses

26 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion: Linguistic Profile The following vignettes provide descriptive examples of high-level linguistic errors made by mtbi subjects

27 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Recreating Sentences: Key semantic elements: before/ rather/ after Defined context: At a movie theatre Response: I d rather see the movie than after difficulty in establishing contextual plan and manipulating/ organising/ monitoring semantic elements at multi-word level of production

28 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Semantic Absurdities: Item: The audience applauded to discourage the performers - encourage/cheer on/ make happy/greet - the audience booed to discourage performers Response: The audience applauded to applaud the performers inability to compare and contrast critical semantic features of conflicting words and recreate underlying meaning of semantically inconsistent message/ stimulus bound

29 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Multiple Definitions: Item: Show Definition references: Display/ demonstrate Movie/ performance Response: To display and To show something stimulus-bound/ inflexible response relative to accessing definition references for words with multiple meanings

30 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Discussion Complex auditory comprehension: Passive and temporal structures: John was hit by Eric. Was John hit? No Does boxing day come before Christmas day? Yes

31 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Conclusion Results support hypothesis of cognitive-communication breakdown in mtbi, evident/ persisting at least 6 months post-injury Deficits identified in domains of: Attention Lexical access Complex lexical-semantic manipulation at sentential level: comprehension and formulation Organisation and monitoring of verbal responses

32 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Conclusion Profile similar to other populations with frontal lobe disconnection syndromes studied in our laboratory (Whelan, Murdoch et al., 2002; 2003;) Support notion mtbi injury mechanisms may also preferentially implicate frontal lobes/ systems involved in recruitment and directed interplay of FL with other language areas possibly via neuronal fall out process/ structural or chemical alterations

33 Cognitive-Linguistic Impairment in mtbi EVIDENCE FOR H-L LANGUAGE DEFICITS Conclusion mtbi may evoke cortical activation cost (Cudmore et al., 2000) reduced abilities Tasks that demand speeded performance, organisation of substantial quantities of information, processing of abstract language, environmental interference or new learning demands (Ylvasaker et al., 1994) More simply, mtbi affects how much and how rapidly information can be processed in contrast to specific and isolated deficits that result from focal brain injury (Gronwall, 1989)

34 Interventions for Cognitive-Linguistic Impairments in mtbi

35 Interventions for Cognitive-Linguistic Impairments in mtbi Neuropsychological literature provides mainstay of data relating to treatment of mtbi Dearth of research conducted in speech-language pathology may be related to lack of detailed profile of cognitive-linguistic impairment Studies to date focus on cognitive rehabilitation interventions rather than linguistic interventions Historically, two approaches utilized in cognitive rehabilitation programs: A process-specific approach directed at improving cognitive processes based on cognitive theory to select treatment targets A functional approach focused on improving independence in performing real-life tasks. Emphasis on adaptation and compensation not restoration of cognitive processes

36 Interventions for Cognitive-Linguistic Impairments in mtbi Contemporary studies have reported efficacious outcomes subsequent to: 1. Process-specific approach to the remediation of working attention/ memory deficits (Cicerone, 2002; Comper et al., 2005 ) 2. The implication of contemporary strategies for functional impairments of memory, attention, reasoning and additional components of executive function (Walker, 2002) Development and application of cognitive communication rehabilitation techniques relative to mtbi population is much needed this should occur as the precise nature of cognitive-linguistic impairment in this population is unravelled

37 Interventions for Cognitive-Linguistic Impairments in mtbi In view of lack of data relevant to mtbi intervention outcomes for cognitive-linguistic function, practitioners often apply treatment strategies and interventions intended for moderate and severe TBI patients While a specific treatment may be effective and necessary in the moderate-severe population, it may be ineffectual and unnecessary in cases of mtbi Whether or not communicative sequelae of TBI are responsive to traditional treatment techniques has yet to be determined

38 Conclusions Historically the diagnostic criteria and assessment instruments applied to mtbi have not been sensitive enough to detect subtle, high-level cognitive-linguistic deficits Only recently has the nature of cognitive-linguistic impairment in mtbi begun to be unravelled through application of more sensitive test batteries Increasing evidence that cognitive-linguistic deficits in mtbi include problems in: Attention Lexical access Complex lexical-semantic manipulation at sentential level Organization and monitoring of responses

39 Conclusions Findings support notion that mtbi mechanisms may preferentially implicate the frontal lobes or systems involved in the recruitment and direct interplay of frontal lobes with other language areas There is currently a lack of research to guide clinicians in the selection and development of efficacious interventions for cognitive-linguistic impairments in mtbi These treatments need to be based on understanding of the precise nature of cognitive-linguistic impairments in mtbi

40 Conclusions Current findings provide a preliminary scaffolding for future studies incorporating: Larger experimental cohorts Integration of behavioural and dynamic neuroimaging measures Correlation of linguistic and neuropsychological performances Application of neurophysiological techniques (e.g. eventrelated potentials) in defining the course of recovery

41 Conclusions Until such time that: 1. Diagnostic and assessment tools sensitive to cognitive-linguistic deficits in mtbi are utilized in clinical settings; 2. The precise nature of cognitive-linguistic impairments in mtbi defined; 3. Efficacious interventions specific to mtbi developed Patients with mtbi will continue to receive inappropriate services with major implications for their social, academic and vocational opportunities

42 Answer to Question Question: Cognitive-linguistic rehabilitation in mtbi = Is there a scientific basis? Answer: Currently NO

43 No head injury is too severe to despair of, nor too trivial to ignore Hippocrates 4th Century BC

44 Thank You

45 Bibliography Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. (2001). Outcome from mild head injury in young children: a prospective study. Journal of Clinical & Experimental Neuropsychology, 23, Beers, S.R. (1992). Cognitive effects of mild head injury in children and adolescents. Neuropsychological Review, 3, Cicerone, K.D. (2002). Remediation of working attention in mild traumatic brain injury. Brain Injury, 16, Comper, P., Bisschop, S.M., Carnide, N., & Tricco, A. (2005). A systematic review of treatments for mild traumatic brain injury. Brain Injury, 19, Cudmore, L.J., Segalowitz, S.J., Dywan, J. (2000). EEG coherence shows altered frontal-parietal communication in mtbi during a dual task. Brain and Cognition, 44, Duff, M.C., Proctor, A., & Haley, K. (2002). Mild traumatic brain injury: assessment and treatment procedures used by speech-language pathologists (SLPs). Brain Injury, 16,

46 Bibliography Goldstein, F.C., Levin, H.S., Goldman, W.P., Clark, A.N., & Altonen, T.K. (2001). Cognitive and neurobehavioural functioning after mild versus moderate traumatic brain injury in older adults. Journal of International Neuropsychological Society, 7, Gronwall, D. (1989). Cumulative and persisting effects of concussion on attention and cognition. In A.L. Benton (ed.), Mild Head Injury, pp New York: Oxford University Press Gronwall, D., & Wrightson, P. (1974). Delayed recovery of intellectual function after mild head injury. Lancet, 2, Gronwall, D. & Wrightson, P. (1981). Memory and information processing capacity after minor head injury. Journal of Neurology, Neurosurgery and Psychiatry, 44, Hanten, G., Dennis, M., Zhang, L., Barnes, M., & Robertson, G. (2004). Childhood head injury and metacognitive processes in language and memory. Developmental Neuropsychology, 25, Hinchliffe, F.J., Murdoch, B.E., & Chenery, H.J. (1998). Towards a conceptualization of language and cognitive impairment in closed head injury: use of clinical measures. Brain Injury, 12,

47 Bibliography Hugenholtz, H., Stuss, D., Stethem, L., & Richard, J.T. (1988). How long does it take to recover from mild concussion? Neurosurgery, 22, Kay, T., Harrington, D.E., & Adam, R. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8, MacFlynn, G., Montgomery, E.A., Fenton, G.W., & Rutherford, W. (1984). Measurement of reaction time following minor head injury. Journal of Neurology, Neurosurgery and Psychiatry, 47, Parker, R.S. (1996). A taxonomy of neurobehavioural functions applied to neuropsychological assessment after head injury. Neuropsychological Review, 6, Walker, J.P. (2002). Functional outcome: a case for mild traumatic brain injury. Brain Injury, 7, Whelan, B-M., & Murdoch, B.E. (2007). Delineating communication impairments associated with mild traumatic brain injury: a case report. Journal of Head Trauma Rehabilitation, 22,

48 Bibliography Whelan, B-M., Murdoch, B.E., Theodoros, D.G., Hall, B., & Silburn, P. (2003). Defining a role for the subthalamic nucleus within operative theoretical models of subcortical participation in language. Journal of Neurology, Neurosurgery and Psychiatry, 74, Whelan, B-M., Murdoch, B.E., Theodoros, D.G., Hall, B., & Silburn, P. (2002). A role for the dominant thalamus in language? A linguistic comparison of two cases subsequent to unilateral thalamotomy procedures in the dominant and non-dominant hemispheres. Aphasiology, 16, Ylvasaker, M., Hartwick, P., Ross, B., & Nussbaum, N. (1994). Cognitive assessment. In G.F. Wolcott (ed.), Educational Dimensions of Acquired Brain Injury, pp Texas: Pro-Ed.

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