Carl Coelho

Intervention for executive functions after traumatic brain injury: A systematic review, meta-analysis and clinical recommendations

A systematic review of studies that focused on the executive functions of problem solving, planning, organising and multitasking by adults with traumatic brain injury (TBI) was performed through 2004. Qualitative and quantitative methods were used to evaluate the 15 studies that met inclusion criteria. Demographic variables, design and intervention features, and impairment and activity/participation outcomes (ICF) (World Health Organization, 2001) were documented. Five randomised control treatment (RCT) studies used step-by-step, metacognitive strategy instruction (MSI) and outcomes were evaluated in a meta-analysis. Effect sizes (ESs) from immediate impairment outcomes after MSI and “control” intervention were similar to each other, and both were significantly larger than chance. ESs from immediate activity/participation outcomes after MSI were significantly larger than the ESs from control intervention, and both were significantly larger than chance. These results, along with positive outcomes from the other group, single-subject design and single case studies, provided sufficient evidence to make the clinical recommendation that MSI should be used with young to middle-aged adults with TBI, when improvement in everyday, functional problems is the goal (Level A) (American Academy of Neurology, 2004). Although maintenance effects were generally positive, there was insufficient data quantitatively to evaluate this. Furthermore, there was insufficient evidence to make clinical recommendations for children or older adults. Intervention that trained verbal reasoning and multi-tasking was promising, although the evidence is insufficient to make clinical recommendations at this time. Additional research needs were highlighted.

Semantic feature analysis as a treatment for aphasic dysnomia: A replication

Semantic Feature Analysis (SFA) is a treatment technique designed to improve lexical retrieval by increasing the level of activation within a semantic network. The purpose of this study was to replicate the Boyle and Coelho (1995) study in which SFA was applied with a mild non-fluent aphasic individual resulting in improved confrontation naming of trained and untrained items but no generalization to connected speech. The present study investigated whether a comparable treatment effect could be demonstrated, and to what extent severity and type aphasia might impact overall outcome. SFA was applied to an individual with a moderate fluent aphasia secondary to a closed head injury. Gains in confrontation naming of both trained and untrained stimulus pictures were noted as well as measures of connected speech. Potential explanations for these findings are discussed.

Phonatory characteristics of Parkinsonian speech before and after morning medication: the ON and OFF states

UNLABELLED After prolonged treatment with L-dopa, patients with Parkinsons disease (PD) experience fluctuations in motor performance. Changes in voice production have been documented perceptually during periods of fluctuation, but few quantitative changes have been found. The purpose of this study is to examine the acoustic-phonatory characteristics of PD speech before and after taking medication, to determine if fluctuations affected phonation. Nine PD patients participated in this study. Multiple analyses were performed, and revealed that fundamental frequency (Fo) variability in vowels and mean Fo were higher, while intensity range was lower in PD patients compared to controls. When the PD subjects were examined after versus before medication, group differences were small, but phonatory improvements were seen in individual subjects. Discussion focuses on physiological changes and variability in PD, and implications of response fluctuations to speech production. LEARNING OUTCOMES As a result of this activity, the participant will be able to (1) acquire knowledge and understanding of PD and the voice characteristics commonly associated with PD and (2) understand the effects of L-dopa-related fluctuations on voice production in PD.

Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years?

This article examines the instructional research literature pertinent to teaching procedures or information to individuals with acquired memory impairments due to brain injury or related conditions. The purpose is to evaluate the available evidence in order to generate practice guidelines for clinicians working in the field of cognitive rehabilitation. A systematic review of the instructional literature from 1986 to 2006 revealed 51 studies meeting search criteria. Studies were analysed and coded within the following four key domains: Population Sample, Intervention, Study Design, and Treatment Outcomes. Coding included 17 characteristics of the population sample; seven intervention parameters; five study design features; and five treatment outcome parameters. Interventions that were evaluated included systematic instructional techniques such as method of vanishing cues and errorless learning. The majority of the studies reported positive outcomes in favour of systematic instruction. However, issues related to the design and execution of effective instruction lack clarity and require further study. The interaction between the target learning objective and the individual learner profile is not well understood. The evidence review concludes with clinical recommendations based on the instructional literature and a call to clinicians to incorporate these methods into their practice to maximise patient outcomes.

Working memory and discourse production abilities following closed-head injury

Primary objectives: This study investigated the relationship between working memory (WM) and narrative discourse production in individuals with closed head injury (CHI). It was hypothesized that those individuals with higher performance on tests of WM would demonstrate better performance on measures of discourse production. Research design: Correlation coefficients were calculated among five discourse measures from two story narratives and scores from three sub-tests of the Wechsler Memory Scale (WMS). Methods and procedures: Fifty-five individuals with moderate-to-severe CHI were studied. Participants included 16 females and 39 males ranging in age from 16–69. Narrative discourse samples were elicited from all participants under two conditions: story retelling and story generation. Main outcomes and results: The results revealed a number of modest, significant correlations (r = 0.29–0.39, p < 0.05) between sub-tests of the WMS and measures of discourse production. Conclusions: Results supported the hypothesis. Story elicitation task differences, limitations of using simple memory span tests as indices of WM and clinical implications of the relationship between WM and discourse production are discussed.

Referential cohesion and logical coherence of narration after closed head injury

A group with closed head injury was compared to neurologically intact controls regarding the referential cohesion and logical coherence of narrative production. A sample of six stories was obtained with tasks of cartoon-elicited story-telling and auditory-oral retelling. We found deficits in the clinical group with respect to referential cohesion, logical coherence, and accuracy of narration. The occurrence of deficits depended on the condition of narrative production and, to some extent, on the particular story used. The primary implications of this study pertain to the attention given by researchers to the feature of discourse production being studied and processing demands of the task.

Conversational discourse in closed-head-injured and non-brain-injured adults

Background: Functional communication requires proficiency in the adaptation of language to varied contexts. Recent research has demonstrated that individuals with traumatic brain injury (TBI) experience difficulty with communicative effectiveness across a variety of discourse genres. Analysis of conversation following TBI is of particular interest because of its importance in the process of socialisation. The development and maintenance of social relationships has been noted to be difficult for individuals with TBI. It has been suggested that these interactional difficulties are the result of social skills deficits which may be a reflection of impaired language use. A variety of analyses have been applied to samples of conversation from individuals with TBI. These analyses have included pragmatic rating scales, exchange structure analysis, Conversation Analysis, as well as measures of topic initiation, topic maintenance, and response appropriateness. Overall, individuals with TBI have been noted to have difficulties with topic management and expressing information in a logical fashion. Further, their conversations have been rated as less interesting, less appropriate, and more effortful. Aims: The present study sought to validate the clinical utility of Blank and Franklins (1980) procedure for analysis of conversation with larger groups of TBI and non-brain-injured individuals. Methods & Procedures: The examiner engaged 32 closed-head-injured (CHI) and 43 nonbrain-injured adults in individual conversations. The conversational performance of each participant, as well as the examiner, were analysed for various dimensions of response appropriateness and topic initiation. Outcomes & Results: Results indicated that the individuals with CHI were dependent on the examiner to maintain the flow of the conversation and that they often contributed information that did not facilitate the social interaction. It was also noted that the examiner compensated by asking more questions and introducing more topics in conversations with the individuals with CHI. In contrast, the conversations with the non-brain-injured controls were characterised by a shared responsibility for sustaining the interactional flow. Conclusions: In general these findings are consistent with previous investigations of conversational skills of individuals with TBI. Blank and Franklins analysis procedure for conversation did delineate differences between the participant groups and in the examiners performance when interacting with these individuals. However, it is important to note that the tenor of the conversational interactions (i.e., the status and roles of the participants) may have constrained the individuals with CHI and therefore their apparent dependence on the examiner may not have been solely the result of their brain injuries.

Direct attention training as a treatment for reading impairment in mild aphasia

Background: Although a variety of interventions for acquired reading disorders have been described in the aphasia literature, most have been designed for severe impairments. Individuals with mildly impaired reading characterised by inconsistent comprehension problems and/or by slower and variable reading rates, do not seem to benefit as much from these treatment approaches. These difficulties suggest relatively intact constituent reading processes that may be functioning inefficiently. Attentional deficits have been described in individuals with a variety of reading disabilities including acquired dyslexia. Although the treatment of nonlinguistic cognitive abilities such as attention has been suggested as an approach to improving language function in aphasia, little evidence exists documenting the treatment effectiveness of such interventions for aphasia in general, or reading in particular.Aims: The present study is a case report of an individual with mild aphasia whose primary complaint was reading difficulty. A treatment approach directed towards improving various aspects of attention was implemented. Aspects of reading were monitored as outcome measures. It was hypothesised that treatment based on attention training would facilitate improvements in this individuals reading.Methods & Procedures: The treatment programme was based on Attention Process Training–II (APT-II) (Sohlberg, Johnson, Paule, Raskin, & Mateer, 2001). The eight-week programme began with activities/tasks addressing sustained attention, and progressed through alternating, selective, and divided attention. Baseline and treatment probes consisted of the individual reading magazine articles and answering comprehension questions. Reading rate was also monitored.Outcomes & Results: The individual treated in this study progressed steadily through the APT-II programme. Treatment effects for improved reading comprehension and decreased reading rate were noted. In addition, changes in pre- and post-treatment test scores, reported reading effort, and reading enjoyment were also documented.Conclusions: The observed reading improvements were not felt to be the result of linguistic recovery. As this individuals proficiency to sustain attention, cope with distractions, and concentrate increased, her ability to read longer, more complex materials also improved. These results are consistent with previous studies that have noted improvements in nonlinguistic cognitive abilities of individuals with aphasia following direct intervention.

Treatment of word retrieval impairment in chronic Broca's aphasia

Background : The present study describes a treatment approach that was applied to improve word retrieval for an individual with chronic Brocas aphasia. The procedure combined elements of loose training with aspects of structured treatment. Treatment involved presentation of semantic cues according to semantic feature analysis [SFA] (Boyle & Coelho, 1995), as well as a forward chaining technique as in response elaboration training [RET] (Kearns, 1985). The technique was intended to elicit the targeted response by activating a semantic network without inhibiting related or creative responses. Aims : The purpose was to investigate whether the combined SFA-RET treatment approach would improve naming accuracy of object noun pictures. This study also focused on an issue related to degradation in word retrieval, but instead of frequency of occurrence the focus was familiarity. Familiarity was based on to how often the individual with aphasia encountered the object nouns in her everyday life. Methods & Procedures : The individual studied, LP, was a 57-year-old, right-handed female who was 8 years post-onset of a left cerebrovascular accident and demonstrated a moderate to severe Brocas aphasia. LPs naming scores were consistent with a severe impairment and the majority of her paraphasic errors were semantic in nature. Treatment materials consisted of 30 photographs of object nouns, of which 15 represented “high-familiarity” objects and 15 represented “low-familiarity”. The 30 pictures were divided into three sets of 10 pictures. Each set consisted of five high- and five low-familiarity objects. Two sets of pictures were designated as treatment stimuli and the third as the control set. The treatment programme was carried out in an ABA single subject design. After the baseline phase the individual with aphasia was treated for 3 hours per week for 6 weeks and was seen for three follow-up sessions 6 weeks later. Outcomes & Results : Results indicated that the combined SFA-RET treatment resulted in improved naming of the treatment pictures as well as the untreated control pictures. In addition, during the treatment phase naming accuracy and consistency were greater for the high-familiarity than the low-familiarity objects. During the follow-up phase it was noted that the treatment effect was maintained at a higher level for the treatment pictures than for the control pictures. A similar trend was observed for the high- versus the low-familiarity words. Conclusions : These findings indicate that the combined treatment approach described was effective in improving this individuals word retrieval of object nouns. However, it is unclear whether the combined approach was necessary or what the individual contributions of each approach were to the final outcome. Finally, it appeared that LP was able to generate semantic features associated with the high-familiarity words and name the stimulus pictures more easily than the low-familiarity words, perhaps because of her regular contact with those objects in her daily life. This finding supports the contention that personalising treatment stimuli can be an important adjunct to any treatment task.

Narrative and conversational discourse of adults with closed head injuries and non-brain-injured adults: A discriminant analysis

Background: Although there is general agreement regarding the clinical utility of discourse analyses for detecting the often subtle communicative impairments following closed head injuries (CHI), there is little consensus regarding discourse elicitation or analysis procedures. Consequently it has been difficult to compare findings across studies. Aims: In an effort to facilitate a movement towards the adoption of a more consistent methodology for the assessment of discourse abilities, the current study examined several commonly used measures of discourse performance and the accuracy with which these measures were able to distinguish individuals with CHI from non-brain-injured (NBI) controls. Previous studies have suggested that conversation is less demanding than narrative discourse because such narratives require greater manipulation of extended units of language while conversational discourse can be maintained with minimal responses (Chapman, 1997; Galski, Tompkins, & Johnston, 1998). On the basis of these reports it was hypothesised that the measures of narrative story performance would more accurately discriminate the participant groups than conversational measures. Methods & Procedures: Discourse samples were elicited from 32 adults with CHI and 43 NBI adults. Discourse samples included two story narratives, generation and retelling, and 15 minutes of conversation. A variety of discourse analyses were performed including story narrative measures of grammatical complexity, cohesive adequacy, and story grammar. Measures of conversation included appropriateness and topic initiation. Discriminant function analyses (DFA) were then employed to determine the accuracy of the selected measures in classifying the participants into their respective groups. Outcomes & Results: Results of the DFA with only the story narrative measures indicated that 70% of the cases, 64.5% of the CHI group, and 74.4% of the NBI group were accurately classified. This finding was not significant, suggesting that the story narrative measures did not reliably discriminate the CHI from the NBI participants. The DFA with the conversational measures correctly classified over 77% of the cases, 78.1% of the CHI participants, and 72.1% of the NBI group. This finding was significant, which suggests that the measures of conversational discourse were better able to discriminate the participant groups. A third DFA was performed, with all of the story narrative and conversational discourse measures included, which revealed that the conversational measures, comments and adequate plus responses, and the story narrative measure, T-units within episode structure in the generation task, made the greatest contributions to discriminating between the groups. Overall, group membership was correctly classified by the DFA in 81% of the cases, 84.4% of the CHI group, and 77.5% of the NBI participants. This finding was significant, suggesting that these three discourse measures discriminated the two participant groups with the highest degree of reliability. Conclusions: These findings did not support the hypothesis that the narrative discourse measures would more accurately predict group membership of the CHI and NBI participants than the conversational measures. A variety of factors may account for these findings including the interactive nature of conversation as well as social factors which appear to make this genre more difficult for individuals with CHI and a more sensitive index of their cognitive-communicative impairments.