Download Evaluating Cognitive-Communication In Persons With Mild TBI

CORNIS-POP, MASHIMA, ROTH
ASHA 2010
EVALUATING COGNITIVE-COMMUNICATION IN PERSONS WITH MILD TBI
Core Measures: well-established measures which cover outcome domains important to many studies
Glasgow Outcome Scale – Extended (GOS-E) – A revision of the Glasgow Outcome Scale, a one-item
scale with 5 possible ratings: dead, vegetative state, severe disability, moderate disability, and good
recovery. The GOS-E provides eight categories of outcome: Dead, Vegetative State, Lower Severe
Disability, Upper Severe Disability, Lower Moderate Disability, Upper Moderate Disability, Lower Good
Recovery, Upper Good Recovery. Ratings are based on patient consciousness, independence, ability to
work, social and leisure activities, social relationships, and other residue from TBI. These scales are the
most commonly used TBI global outcomes and there is an extensive literature demonstrating reliability
and validity for these scales. Use of these scales permits comparisons among international research on
TBI outcomes.
Rey Auditory Verbal Learning Test (RAVLT) – A word list learning task that takes approximately 10
minutes to administer that can be administered to individuals ranging in age between 7 and 85+ years.
One of the most extensively studied neuropsychological performance measures consisting of 15
unrelated words repeated 5 times with recall after each presentation. The test requires immediate recall
and delayed recall and recognition. The instrument has extensive normative data and meta-norms, good
psychometric properties, and has been used in different languages, cultures, and ethnic groups.
California Verbal Learning Test (CVLT)—similar to RAVLT and studies have shown high correlations of
performances between two tests for persons with TBI.
Trail Making Test (TMT) – Measure of attention, speed and mental flexibility and is sensitive to cognitive
impairment associated with TBI. Brief test with good reliability. Available in adult and child forms and
demographically-adjusted normative data are available for ages 20-85 years. Practice effectds are found
over short retest intervals, but disappear after several administrations and only modest change is seen
among healthy adults after longer intervals. Performance on TMT declines with aging.
Wechsler Adult Intelligence Scale (WAIS III) Processing Speed Index – This Index is derived from the
Digit Symbol Coding and Symbol Search subtests of the WAIS III. This measure represents the amount
of time it takes to process a set amount of information, or the amount of information that can be
processed within a certain unit of time. As part of the WAIS, it has extensive normative data and
excellent psychometric properties. It is clinically one of the most sensitive cognitive measures to
neurologic conditions. It is culturally, racially, and ethnically sensitive.
Rivermead Post Concussive Symptom Questionnaire (RPQ) – 16-item self-report measure of the
presence and severity of the 16 most commonly reported post-concussive symptoms found in the
literature. The scale compares current symptoms to preinjury levels to account for potential symptom
exacerbation due to TBI. The range of scores is 0-64 with values for each of 16 items rated 0 (not
experienced at all), 1 (no more of a problem than before the injury), 2 (mild problem), 3 (moderate
problem), and to 4 (severe problem). The total score is a summation of symptoms rated as >2 indicating
post-concussion symptoms or an exaceration of a symptom present preinjury. Requires 5-10 minutes to
complete. Most useful in assessing post-concussion symptoms in persons with mild to moderate TBI.
Can be used for diagnostic and severity purposes, as well as to monitor change in response to treatment.
The RPG is in public domain and is a widely used measure.
Brief Symptom Inventory – 18 Item (BSI-18) – This instrument is a short form of the Symptom
Checklist-90-R. It is designed to provide a brief self-report measure of psychological distress and has
three subscales (Depression, Anxiety, and Somatization), as well s a Global Severity Index. The selfreport measure consists of 18 items rated on a 5-point rating scale, and can be completed manually or
computerized administration. The BSI 18 provides a brief, global assessment of common psychological
2 issues in individuals with TBI, and has sound psychometric characteristics. It can be used for initial
assessment, as well as to monitor change in response to treatment.
Functional Independence Measure (FIM) – an 18-item ordinal scale, used with all diagnoses with a
rehabilitation population. The FIM measures degree of independence in activities of self-care, sphincter
control, transfers, locomotion, communication, and cognition. The FIM scores range from 1 (total or >75%
assistance) to 7 (complete independence). Total scores range between 18-126. Subscores are available
for motor and cognitive items. Scores may be used raw or converted to interval scores. The FIM is most
useful as a measure of progress during inpatient rehabilitation. It has extensive normative data and
excellent psychometric properties. It is most appropriate for Severe and Moderate disability levels of
GOSE; ceiling effects limit utility in Good Recovery. The FIM is not sufficiently sensitive for mild TBI.
Craig Handicap Asses & Rep Tech (CHART-SF) – Objective measure of the degree to which
impairments and disabilities impact participation consisting of 19 items that comprise 6 subscales:
Physical Independence, Cognitive Independence, Mobility, Occupation, Social Integration, and Economic
Self Sufficiency. Each subscale has a maximum score of 100 corresponding to the level of performance
typical for a person without a disability. Subscale scores can be added to obtain a Total Score (maximum
= 600). Easy to administer. Best used with adults with moderate to severe disability and those who make
a good recovery. It has demonstrated good reliability and validity in the TBI population.
Satisfaction With Life Scale (SWLS) – A five item global measure of life satisfaction completed by the
individual whose life satisfaction is being measured. The SWLS has shown consistent differences
between populations that would be expected to have different qualities of life (e.g. psychiatric patients or
male prison inmates). The SWLS ahs been found to change in the expected directions in response to
major life events, and in patients receiving psychotherapy.
JFK Coma Recovery Scale – Revised (CRS-R) – Standardized behavioral assessment instrument
designed to measure neurobehavioral function in patients with disorders of consciousness. It is
comprised of six subscales designed to assess auditory, visual, motor, oromotor/verbal, communication
and arousal functions. The CRS-R is the only standardized assessment measure that directly
incorporates the diagnostic criteria for coma, vegetative state, minimally conscious state (MCS) and
emerging from MCS. The scale is intended for use by medical and allied health professionals. The CRSR has strong diagnostic sensitivity and specificity, correlates well with functional outcome, is useful for
monitoring treatment effectiveness and is available in 9 languages.
Additional Global Measures
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Mayo-Portland Adaptability Inventory (4 edition; MPAI-4) – 30 items rated on a 5-point scale ranging
from normal for age to severely restricted. Items selected represent key indicators in three interrelated
subdomains represented by three subscales. Ability index (physical and cognitive abilities), Adjustment
Index (emotional and behavioral self regulation, interpersonal activities), Participation Index (community
integration). An overall score and scores for each index may be obtained. Specified modifications to the
rating scales allow the measure to be applied across the age span for childhood through adulthood.
Quality of Life after Brain Injury (QOLIBRI) – disease-specific health-related quality of life (HRQOL)
tool devoted to TBI made up of a multidimensional structure containing 37 items on 4 satisfaction scales
“Cognition”, “Self”, Daily Life & Autonomy”, “Relationships”, and 2 “Bothered scales “Emotions” and
“Physical Problems” and a total score. There is an additional overall scale available with 6 items that can
be used for screening purposes. Percent scores are available for the six subscales (with 100% indicating
best QOL), and one total score. Higher scores on all scales indicate higher HRQOL after TBI. The
questionnaire is validated in German, Finnish, Italian, French, English, Dutch and requires just 15 minutes
to complete. Validation in 8 additional countries is in progress. (Computer Adaptive Test (CAT) in
preparation.www.qolibri-international.com)
3 WHOQOL-BRIEF – developed as an international cross-culturally comparable quality of life assessment
instrument. It assesses the individual’s perceptions in the context of their culture and value systems, and
their personal goals, standards and concerns. The WHOQOL was developed in locations worldwide and
has been widely field-tested. The WHOQOL-BREF instrument comprises 26 items, which measure the
following broad domains: physical health, psychological health, social relationships, and environment.
This instrument is a shorter version of the original instrument
Disability Rating Scale (DRS) – A measure of general functioning over the course of recovery, the DRS is
comprised of three areas of functioning including level of arousal, cognitive ability to perform basic
activities of daily living including eating, grooming, and toileting and level of functioning including level of
dependency and employability. It is applicable across a wide range of injury severity and recovery
intervals. It may be useful in studies of moderate to severe TBI with serial measurement, particularly
where initial measurement occurs in the acute post-injury interval.
Short Form-36 Medical Outcome Study (SF-36v2)—This widely used subjective health status measure
asks 36 questions to measure functional health and well-being from the individual’s point of view. It is a
practical, reliable, and valid measure of physical and mental health that can be completed in 5-10
minutes. The subscales comprise physical functioning, physical role function, emotional role function,
bodily pain, vitality, mental wellbeing, social functioning, and general health perception. An additional
item measures change in health status during the previous year. A physical component score (PCS) and
a mental component score (MCS) can be computed. This instrument has been used extensively in TBI
research and has been shown to be sensitive to treatment related changes.
Community Integration Outcomes (CIQ) – Developed to provide a measure of community integration
after TBI that could be used in the TBI Model Systems program. Designed to be brief, administered in
person or telephone interview and conducted with the person with TBI or with a proxy. Focus was on
behaviors rather than feeling states; and without biases resulting from age, gender or socioeconomic
status; sensitive to a variety of living situations and value neutral. The CIQ consists of 15 items relevant
to home integration (H0), social integration (S), and productive activities (P). Subtotals are calculated for
each of these domains as well as for community integration overall.
Participation Assessment with Recombined Tools (PART) – A measure of community participation
developed by the Traumatic Brain Injury Model Systems (TBIMS) by combining the primary measures
found in the TBI literature (Community Integration Questionnaire, original and revised, Participation
Objective, Participation Subjective (POPS), and the Craig Handicap and Assessment Reporting
Technique). The psychometric data on the scale have not yet been published.
Cognitive-communication measures
The American Speech-Language-Hearing Association Functional Assessment of Communication
Skills (ASHA-FACS) -- A questionnaire that was designed as a “means for assessing functional
communication behaviors at the level of disability in a valid, reliable, sensitive yet efficient manner”. It was
standardized on a group of 54 individuals with cognitive-communication impairments from mild, moderate
and severe TBI. The overall score from the FACS is significantly correlated with other cognitive tests and
the LOCF, but contributes unique variance attributable to factors in daily living not captured by other
standard measures.
Cognitive-Linguistic Quick Test (CLQT) – A screening tool that assesses five cognitive domains:
attention, memory, language, executive functions, and visuospatial skills. For this study, two subtests
have been selected: Symbol Cancellation and Clock Drawing. Symbol Cancellation is a nonlinguistic task
that assesses visual attention, scanning, and visual discrimination. Abstract symbols are arranged in what
appears to be a random pattern, with the target stimulus appearing three times in each quadrant. Other
abstract symbols serve as foils. Information is collected on errors of omission (failure to cancel targeted
symbols) and errors of commission (cancellation of foils). Clock Drawing is a commonly used screening
for neurological dysfunction. This CLQT version provides a standardized scoring system that permits
analysis of language, visuospatial planning skills, and conceptualization of time. The CLQT was normed
on 171 non-clinical cases and 38 clinical cases, including TBI. It establishes criterion-referenced cut-off
4 scores within each task and severity ratings based on the distribution of scores of the clinical and
nonclinical subjects.
The Discourse Comprehension Test (DCT) – A test of narrative comprehension. Individuals listen or
read narratives and answer yes/no questions that tap comprehension for explicit (stated or implied) and
salient (main ideas and details) information.
Measure of Cognitive Linguistic Abilities (MCLA) -- Designed to provide a systematic evaluation of
clients who have mild to moderate impairments cased by TBI. The MCLA has three major purposes as
stated in the manual: 1) To assess linguistic abilities, 2) To help identify cognitive deficits that have an
impact on linguistic performance, and 3) To recognize the important interrelationship between cognition
and language. The test was standardized on 204 healthy, English-speaking adults ages 16-50 with no
history of TBI or other neurologic disorder.
Ross Information Processing Assessment (RIPA-2) -- Proposes to assess cognitive-linguistic
functioning in clients with traumatic brain injury.
Standardized on a sample of 126 persons with TBI between 15-77 years of age from 9 states;
representative of TBI cases relative to gender, area of residency, geographic area, and ethnic
background as described in TBI literature relative to demographic information.
Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) -- Provides a systematic method for
assessing cognitive deficits associated with traumatic brain injury. 244 patients with TBI from 26 sites in
U.S. and Canada. Consisted primarily of patients who suffered closed-head injuries.
LaTrobe Communication Questionnaire (LCQ) -- 30 item questionnaire that measures perceived
cognitive-communication ability in adults after severe traumatic brain injury by collecting data from
different sources including self-perceptions and perceptions of others. Content and test-retest reliability
and discriminant validity of the LCQ have been demonstrated with adults following TBI. The
questionnaire has been shown to be sensitive to the effect of severity of injury.
Attention Process Training APT II (APT III will come out soon) – This is a program is for treating
impairments in attentional processing in persons with relatively mild cognitive disturbance, such as postconcussion syndrome. Activities address difficulties with sustained attention, slowed speed of information
processing, distractability, shifting attention between multiple tasks, and paying attention to more than
one source of information at a time. The manual has a placement test to determine the level at which
treatment should be initiated. The program has an Attention Questionnaire that can be used to determine
treatment effect.
Test of Everyday Attention (TEA) -- The TEA gives a broad-based measure of the most important
clinical and theoretical aspects of attention. The TEA can be used analytically to identify different patterns
of attentional breakdown. Originally standardized on 154 normal volunteers in Australia, ranging in age
from 18-80, stratified into 4 age groups and 2 levels of educational attainment; in addition, 80 unilateral
stroke patients were given TEA 2 months post-CVA. The test has been validated successfully with closed
head injured patients, stroke patients, and patients with Alzheimer’s Disease, including those of low
educational level.
Behavioural Assessment of the Dysexecutive Syndrome (BADS) -- Specifically assesses the skills
and demands involved in everyday life. It is sensitive to the capacities affected by frontal lobe damage,
emphasizing those usually exercised in everyday situations such as temporal judgment, thought flexibility,
problem solving, strategy formation, and planning.
Dysexecutive Questionnaire (DEX) – A rating scale designed to sample everyday problems commonly
associated with frontal system dysfunction. The DEX was used as a validation tool for BADS, although it
is not a formal part of the BADS. The DEX can also be used as a measure of awareness, by calculating
the discrepancy score between self and informant responses. The DEX comprises 20 items sampling four
domains: emotional, motivational, behavioral, and cognitive.
5 The Functional Assessment of Verbal Reasoning & Executive Strategies (FAVRES) -- was designed
to assess verbal reasoning, complex comprehension, discourse, and executive functioning with functional
tasks that challenge even those with subtle cognitive-communication disorders. The test requires
processing of ‘real life’ amounts of verbal information, analysis of multiple facts and goals, integration of a
variety of types of stimuli, and formulation of written and oral responses. Its strength is its ecological
validity in that tasks simulate real world communications and incorporate context using natural settings,
roles, and conversation. It is standardized on healthy controls and individuals with brain injury, ages 1879.
Rivermead Behavioural Memory Test (RBMT) -- The goal of this test is to detect impairment of
everyday memory functioning and to monitor change following treatment for memory difficulties. The test
was initially standardized in the UK on a sample of brain damaged patients and a sample of 118 healthy
subjects aged 16-69 years with a mean IQ of 106. The RBMT has since been standardized with
community-dwelling elderly people aged 70 years and over, with healthy adolescents aged 11- 14 years,
and with children aged 5- 10 years.
Comprehensive Assessment of Prospective Memory (CAPM) – The CAMP is a self-rating scale,
designed to measure specific, everyday prospective memory lapses. The CAMP comprises three
sections. Section A contains 39 items examining perceived frequency of failure. It contains two
statistically derived components: basic ADLs and IADLs. Section B uses the same 39 items from Section
A to assess concerns about failures. Section C contains contains 15 items focusing on reasons
associated with successes/failures. The CAMP was originally developed for older people, but has also
been use with young people and people with TBI.
Participation Objective Participation Subjective (POPS) – The POPS consists of a list of 26 items
comprising of elements of participation (e.g., going to the movies, housework, opportunities to meet new
people). Two types of questions are presented: objective questions and subjective questions. The 26
items are sorted into five categories: Domestic Life; Major Life Activities; Transportation; Interpersonal
Interactions and Relationships; and Community, Recreational and Civic Life. The test was designed with
the TBI population in mind but the items refer to normative activities.
Doors and People -- Doors and People is a broad-based test of long-term explicit memory It yields a
single age-scaled overall score with separate measures available for visual and verbal memory, recall
and recognition, and forgetting. It is designed for use both as a clinical tool and as a research instrument.
The test comprises four subcomponents: visual recognition, visual recall, verbal recognition, and verbal
recall. Factor analysis of an age-stratified sample of 238 normal subjects indicated a strong general
memory factor, followed by a weaker visual/verbal factor. Studies indicate that the test is sensitive across
a wide range of abilities, from elderly patients with Alzheimer’s disease, of low educational level, to young
graduate students.
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) – RBANS is a brief
neurocognitive battery designed to detect and track declining neurocognitive deficits in dementia and
other disorders. It is comprised of four alternate forms, that measure immediate and delayed memory,
attention, language, and visuospatial skills.
Speed and Capacity of Language Processing (SCOLP) – SCOLP is a measure of the slowing in
cognitive processes that can be experienced by individuals with brain damage. It can differentiate
between individuals who have always been slow and individuals whose performance reflects impairment
as a result of brain damage or some other stressor. It is sensitive to the effects of TBI, normal aging,
Alzheimer’s disease, schizophrenia and to a wide range of drugs and stressors, including alcohol.
Stroop Color and Word Test (Stroop) -- This test measures the Stroop Effect, described by John Ridley
Stroop in 1935, which shows how one area of the brain can dominate and inhibit other functional areas.
The cognitive dimension tapped is associated with cognitive flexibility, resistance to interference from
6 outside stimuli, creativity, and psychopathology, all of which influence the individual’s ability to cope with
cognitive stress and to process complex input.
Prospective Memory Training Screening (PROMS) – The PROMS samples prospective responding to
both time and event cues. Prospective memory has been shown to relate to attention and to various
other executive functions, especially relevant to everyday memory demands. A modification of this test,
the Prospective Memory Test, was developed by Raskin & Buckheit, 1998 that provides a larger number
of tasks, including action and verbal tasks and provides a system for scoring a number of different types
of errors.
Pragmatics Rating Scale -- A pragmatic communication scale established and based on assessments of
144 subjects with TBI. The assessment is based on a rating scale of pragmatic behaviors developed for
the Defense and Veterans Brain Injury Center. The scale measures nonverbal, verbal, and interactional
aspects of communication, based on samples of conversation, narrative discourse, and procedural
discourse.
Boston Naming Test (BNT-2) -- The Boston Naming Test (BNT) consists of 60 black and white line
drawings of objects. It measures confrontation naming. This type of picture-naming vocabulary test is
useful in the evaluation of adults with brain injury.
Delis-Kaplan Executive Function System (D-KEFS) -- Standardized set of tests to evaluate higherlevel cognitive functions in children and adults. Consists of nine stand-alone tests, comprehensively
assessing the components of executive functions mediated primarily by the frontal lobe.
Woodcock-Johnson-III (WJ-III) – The WJ-III consists of 7 cognitive tests and 11achievement tests that
measure general intellectual ability and specific cognitive abilities; including short term memory, long term
retrieval, processing speed, auditory processing, visual processing, comprehension-knowledge and fluid
reasoning. In addition, a few subtests evaluate performance in a controlled-learning context: visualauditory learning, concept formation, and analysis-synthesis. Normative data is available for ages 2
through 90+ and has been used extensively in the educational model for evaluating students of all ages
with learning disabilities, including those with acquired TBI. In a study of the relationship of the Automated
Neuropsychological Assessment Metrics (ANAM) and the WJ-III, Jones et al (2008) demonstrated a
strong relationship between these measures of cognitive function.
Behavior Rating Inventory of Executive Function (BRIEF-Adult) -- BRIEF-A is used to assess
executive functioning in adults up to 90 years of age. Results are useful for evaluating and planning
treatment strategies for a wide spectrum of developmental and acquired neurological conditions including,
ADHD, Tourette’s disorder, Traumatic Brain Injury, and Autism. It is suitable for individuals who have
been diagnosed with developmental, systemic, neurological, or psychiatric disorders. The eight
nonoverlapping clinical scales form two broader indexes: Behavioral Regulation (three scales) and
Metacognition (five scales). A Global Executive Composite score is also produced.
Multiple Errands Test -- Multiple Errands Test was developed to reflect how executive impairments are
manifested in the context of everyday functioning. It was designed for people who performed within or
above the normal range when tested using existing psychometric measures. The procedures were
administered and subjects tested in a public place. Knight, Alderman, and Burgess (2002) explored an
abbreviated hospital-based version of the test.
Awareness Questionnaire (AQ) -- Developed as a measure of impaired self-awareness after TBI. The
AQ consists of 3 forms to be completed by: the individual with TBI, a family member or significant other,
and a clinician.
7 References
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