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8. Their outcomes
9. Summary
Leanne.togher@sydney.edu.au
2
Effects of a TBI
Train both
Conversation
Rewarding and important part of our social interactions
Medd & Tate, 2000, Tate, 1987, Cannizzaro & Coelho, 2002; Cramon et al, 1992,
Helffenstein & Wechsier, 1982, McDonald et al., 2008, Dahlberg et al., 2007).
ICD
Impairments
Limitations
+ Facilitators - Barriers
Restrictions
A study of 273 caregivers across six Traumatic Brain Injury Centers in the
USA, found that one-third of caregivers are at risk for depression,
anxiety, or other forms of psychological distress
Bogart, E., Togher, L., Power, E. & Docking, K. (2012). Casual conversations
between individuals with traumatic brain injury (TBI) and their friends, Brain Injury,
26 (3), 221-233.
TBI Express- first of its kind to train everyday partners (i.e. family, friends,
carers) and the person with TBI.
Kilov, A., Togher, L. & Grant, S. (2009) Problem solving with friends: Discourse
participation and performance of individuals with and without traumatic brain injury,
Aphasiology, 23 (5), 584-605.
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Case study
AS, 21 yr old male
18 mths post injury MVA (water sports)
Lives at home with parents and 2 younger siblings
University student, medical science (14 years education)
Bilateral brain injuries
PTA = 127 days
- How
- appropriate,
1.
- interesting (engaging),
2.
- effortful,
- rewarding
1.
Interaction (feel)
2.
Transaction (content)
- To extend conversations
TBI Express
http://sydney.edu.au/health-sciences/tbi-express/
Collaboration
Elaboration
Question asking
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Training Program
Collaborative style
Session 1: Introduction.
Aims of training, group guidelines, home practice expectations established
Session 2: TBI and communication.
Educational on TBI, cognition & communication.
http://www.tbistafftraining.info/Presenters/Module2/2Intro.htm
Sessions 3, 4: Effective communication 1 and 2.
Explores communication roles and rules in society as well as general
communication strategies.
Session 5: Collaborative conversation. we are doing this together as a
co-operative project
Training collaboration where both the feel and information exchange are
more equal, shared and organised.
Aims
To provide you with an overview of collaborative style and highlight collaboration styles for
speakers and listeners
To practise identifying and using positive collaborative styles
Resources to bring
BREAK
Equipment
Handouts
Other
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COLLABORATION
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Collaborative
X Non collaborative
Shares information
Demands information
Confirms partners
contributions
Shows enthusiasm
Communicates respect
Fails to acknowledge
difficulties
Questions in a non
demanding, supportive
way
Lack of enthusiasm
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Example
E.g., collaborative methods could be used to plan a barbecue
Person with TBI says:
Collaborative intent
Shares information
Uses collaborative
talk a team effort
So what options do we
Provides information
rather than asking lots of have?
questions
What do you think is
the best way to do this?
Gives own opinions
Lets think about the
advantages of doing
that.
Types of collaboration
COGNITIVE SUPPORT
LACK OF COGNITIVE
SUPPORT
Gives cues in a
conversational manner
Corrects in a punishing
manner and considers
accuracy more important
than the message
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EMOTIONAL
SUPPORT
Cast your mind back Create an image of the scene you are going to
talk about.
LACK OF EMOTIONAL
SUPPORT
Think about the parts Break the situation down into its parts (e.g.
places, people, time) and discuss the different parts individually
Use a different method Draw a picture of the scene, tell it as a story
focussing on the perspectives of the different people involved
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Types of collaboration
Fails to acknowledge
difficulty of the task and
continues despite
difficulties
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Types of collaboration
QUESTIONS:
POSITIVE STYLE
QUESTIONS:
NEGATIVE STYLE
Questions in a demanding
manner (quiz like)
Questions in a supportive
manner (e.g. Did we go
swimming after that? vs.
What did we do yesterday?)
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Types of Collaboration
COLLABORATIVE
TURN TAKING
Takes appropriate
conversational turns
Helps partner express
thoughts when struggle
occurs (word finding
difficulties)
NONCOLLABORATIVE
TURN TAKING
Interrupts in a way that
disrupts the partners
thought processes and
statements
Fails to help partner
when struggling occurs
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Training Program
Session 6. Elaborative conversation.
I am going to help you organise and extend your thoughts.
Training on helping person with TBI to keep conversations going and to widen
topic repertoire. Also learn how to organise and link simple and more complex
topics together.
e.g., encourages CP to use scaffolds for person with TBI assuming you need to
GIVE info: We went to dinner on FridaySaturday was a bit
different..Sunday was pretty lazy.
Elaborative
X Non elaborative
Introduce topics of
interest
Add information to
help develop topics
Organises information
Makes connections
when topics change
Changes topic
frequently
Fails to make
connections from one
day to the next
Question asking
Good questions
X Poor questions
3 arm trial which compares:
Open ended
Closed
True questions
- Feelings
- Testing performance,
memory
- Opinions
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TBI Participants
44 participants with severe TBI (38 males, 6 females)
Recruited from Liverpool, Royal Ryde and Westmead Brain Injury
Units, Sydney, Australia
Study Participants
Allocated to
TBI JOINT - Communication partner treatment
n=14 ( 1 dropout = 13)
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Control condition
Waitlist group
deferred treatment
No communication partners
2 therapists
2.5 hr weekly group sessions (with morning tea/social break)
1 hour weekly individual sessions
10 week program
Manualised approach parallels JOINT contents
Session 1: Introduction
Aims of training, group guidelines and home practice expectations established.
Explores use of helpful questions and how avoid using negative, or testing
questions.
12
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50
51
52
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Where? What situation are they in? What are the physical features?
When? What time of day, or stage of their life?
54
appointment).
Write out a plan of the main points you would need to cover in the
conversation.
55
56
14
Treatment fidelity
Outcome measures
Primary outcome measures (blinded)
Qualitative interviews
Fully complete
Partially complete
Not completed
57
press)
Measure of Participation in Conversation (TBI)
58
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Analysis
Secondary measures
Adapted Measure of Support in Conversation (MSC)(Kagan et al.,
2001,2004; Togher et al, in press)
Global ratings of communication (Bond & Godfrey, 1997)
Appropriate
Effortful
Interesting/engaging
Rewarding
on a 9 point scale, 0-4
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RESULTS
64
63
16
Results
PC = Purposeful
conversation
65
66
PC = Purposeful
conversation
CC = Casual
conversation
67
68
17
Yes!!
Yes !!
71
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Discussion
Change of mind set for Mother
76
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Discussion
Discussion
Training communication partners had advantages
Conclusion
Important to work with the person with acquired brain
injury and their families
Increasingly recognised that it is our role to work with
members of the community to facilitate social engagement
and acceptance
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Research translation
TBI Express
http://sydney.edu.au/health_sciences/disability_comm
unity/tbi_express/
20
82
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Collaborative behaviours
Research translation
87
22
Summary
Conclusions
89
90
Acknowledgements
Telehealth Assessment
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www.speechbite.com
speechBITE 2013
ACCESS:
Search for
evidence
ASK: Pose
an
answerable
question
APPRAISE:
Critically
appraise the
evidence for its
validity and
relevance
APPLY: Make a
decision by
integrating
evidence with
clinical
experience
ASSESS:
Evaluate
performance
after acting on
evidence
Image: http://www.bestgatewaytosuccess.com/images/FREE.jpg
speechBITE 2013
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INCOG
INTERNATIONAL TRAUMATIC BRAIN INJURY
COGNITIVE REHABILITATION (INCOG) GUIDELINE
Togher, L., Wiseman-Hakes, C., Turkstra, L., Douglas, J., Bragge, P., Bayley, M.,
Stergiou-Kita, M., Ponsford, J. & Teasell, R. (2014). INCOG recommendations for
management of cognition following TBI: Part IV: Cognitive Communication. Journal
of Head Trauma Rehabilitation, 29(4), 353-368.
Cog Comm #7. Interventions to address patient identified goals for social
communication deficits are recommended after TBI, with outcomes
measured at the level of participation in everyday social life. These
interventions can be provided in either group or individual settings,
however published evidence is strongest for group-based interventions
(adapted from Cicerone et al. 2011).
100
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IMPAIRED
COMMUNICATION?
Referral to SLP
Evaluate communication
Consider premorbid native
language, literacy, and language
proficiency; communication
style; cultural expectations;
fatigue; and personal factors
No
Yes
Treat
Aphasia*
Severe
Communication
Deficit?
Yes
Cognitive-Communication Rehabilitation
Ingredients for all rehabilitation:
Consider communication partner, environment, and demands
Provide opportunity to rehearse communication skills in situations
appropriate to where patients will live, work, study, and socialize after
discharge
Group-Based Treatment
of Social Communication
Skills
(+/- Individual Treatment)
With Involvement of
Communication Partners
No
Ingredients:
Augmentative
Device
Assessment
and Training
CognitiveCommunication
Rehabilitation
Client-centered goals
Tailor therapy to clients
neuropsychological profile
Communication Partner
Training
Ingredients:
Teach partners to ask
questions in a positive,
non-demanding manner
Encourage discussion of
opinions e.g. TBI Express
program
101
For more on the NH& MRC training study called TBI express see:
- Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk, R. (2009). Training communication partners
of people with TBI: Reporting the protocol for a clinical trial. Brain Impairment, 10(2), 188-204.
2.
For more info on the two different conversation rating scales see:
- Bond, F., & Godfrey, H. P. D. (1997). Conversation with traumatically brain-injured individuals: a
controlled study of behavioural changes and their impact. Brain Injury, 11 (5), 319-329.
- Kagan, A., Winckel, J., Black, S., Duchan, J. F., Simmons-Mackie, N., & Square, P. (2004). A set of
observational measures for rating support and participation in conversation between adults with
aphasia and their conversation partners. Topics in Stroke Rehabilitation, 11(1), 67-83.
- Togher, L., Power, E., McDonald, S., Tate, R., & Rietdijk, R. (in press, June 2010). Measuring the
social interactions of people with traumatic brain injury (TBI) and their communication partners: the
adapted Kagan scales. Aphasiology.
3.
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Togher, L., McDonald, S., Code, C., & Grant, S. (2004). Training communication partners of
people with traumatic brain injury: a randomised controlled trial. Aphasiology, 18(4), 313-335.
Kagan, A., Black, S. E., Duchan, J. F., Simmons-Mackie, N., & Square, P. (2001). Training
volunteers as conversational partners using "Supported Conversation with Adults with Aphasia"
(SCA): A controlled trial. Journal of Speech, Language and Hearing Research, 44, 624-638.
Turner, S., & Whitworth, A. (2006). Conversational partner training programmes in aphasia: A
review of key themes and participants' roles. Aphasiology, 20(6), 483-510.
5.
Togher, L., Wiseman-Hakes, C., Turkstra, L., Douglas, J., Bragge, P.,
Bayley, M., Stergiou-Kita, M., Ponsford, J. & Teasell, R. (2014). INCOG
recommendations for management of cognition following TBI: Part IV:
Cognitive Communication. Journal of Head Trauma Rehabilitation, 29(4),
353-368.
Ponsford, J., Bragge, P., Wiseman-Hakes, C., Togher, L., Tate, R.,
Velikonja, D., Green, R., Marshall, S. & Bayley, M. (2014). INCOG
Recommendations for management of cognition following TBI Part II:
Attention and information processing speed. Journal of Head Trauma
Rehabilitation, 29(4), 321-337.
Ylvisaker, M., Feeney, T. J., & Urbanczyk, B. (1993). Developing a positive communication culture
for rehabilitation: Communication training for staff and family members. In C. J. Durgin, N. D.
Schmidt & L. J. Fryer (Eds.), Staff Development and Clinical Intervention in Brain Injury
Rehabilitation (pp. 57-81). Gaithersburg, MD: Aspen.
Ylvisaker, M., Sellars, C. & Edelman, L. (1998). Rehabilitation after traumatic brain injury in
preschoolers. Traumatic brain injury rehabilitation. Children and adolescents. M. Ylvisaker. (Ed.)
Newton, MA, Butterworth-Heinemann: 303-329.
http://www.bianys.org/learnet/tutorials/conversation_and_cognition.html
INCOG references
105
106
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