Overview

Communication treatment approaches for

people with ABI

1. Communication training for people with TBI

2. The role of communication partners
3. Case discussion - introduction to AS and his mother

City University, London, UK

26 February 2016

4. Video casual conversation pre Trt

5. Assessing communication partner contributions
6. TBI express: A communication partner training program
7. Video casual conversation post Trt

Professor Leanne Togher

NHMRC Senior Research Fellow
Speech Pathology
The University of Sydney

8. Their outcomes
9. Summary

[Link]@[Link]
2

Effects of a TBI

Approaches to improve communication in TBI

Train the person with TBI

(Flanagan, McDonald & Togher, 1995, Medd & Tate, 2000, Tate, 1987,
Cannizzaro & Coelho, 2002; Cramon et al, 1992, Helffenstein & Wechsier,
1982 ; Dahlberg et al., 2007); McDonald et al., 2008)

Train communication partners

(Togher,

McDonald, Code & Grant, 2004)

Train both

(Images courtesy of Professor Erin D. Bigler and Trevor Wu)

Conversation
Rewarding and important part of our social interactions

Communication training for people with TBI

Conversational skill influences the ability of people to develop social

relationships, return to work, maintain friendships and interact with their
families

Training the person with TBI in social communication skills is possible,

although gains are often modest due to other cognitive and executive
functioning deficits (e.g. poor memory) (Flanagan, McDonald & Togher, 1995,

Maintains and develops close relationships

Solve problems
Work out personal issues
Share our history

Medd & Tate, 2000, Tate, 1987, Cannizzaro & Coelho, 2002; Cramon et al, 1992,
Helffenstein & Wechsier, 1982, McDonald et al., 2008, Dahlberg et al., 2007).

Make sense of the present

Plan for the future

Communication is a dynamic exchange involving others so we need to

look at Environment (ICF, WHO, 2001)

ICF framework adapted from WHO (2001)

Communication partners can be a barrier:

ICD

Impairments

Limitations

+ Facilitators - Barriers

The role of communication partners

Overcompensating by speaking too slowly / quickly

Not giving TBI opportunity to communicate

Failing to provide natural consequences for communication

successes / failures

Talking for the person

Questioning the accuracy of responses

Asking testing questions (Togher, Hand, & Code, 1997).

Restrictions

The role of communication partners

Families of people with TBI

Communication partners can be Facilitators:

Family strain, emotional distress, caregiver burden, and social isolation

Different communication partners such as friends may provide a facilitative

environment (Bogart et al., 2012, Kilov et al., 2009).

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

If trained, communication partners can enhance the communicative

competence of people with severe TBI.

A main source of stress is difficulty communicating with the person with

TBI (MAA, 1998)

- Police study (Togher, McDonald, Code & Grant, 2004)

Training communication partners is more common in aphasia (e.g.,

Simmons-Mackie et al 2010), but there are few studies in TBI

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

Pre -assessment results for AS

Poor communication with others, socially isolated (but previously popular)
Mother doesnt trust him to organise own activities, rarely see friends
Not back at university
Difficulty reading conversational and emotional cues
(TASIT: Part 1=21, Part 2=29, Part 3 =36 (lower 5th %ile))

Good performance on cognitive ability in impairment based test

Mother
50 yr old female
17 years education
Home duties (previously a primary school teacher)

(SCATBI) %ile rank=97, Severity score =16

Very poor verbal reasoning and executive strategies on an activity-based

real life test
(FAVRES) Extremely slow completion of tasks (<1st %ile).

Assessment / outcome scales - 1

Adapted Kagan scales (Togher et al. 2010) reliable scales adapted

Assessment / outcome scales - 2

Global impression scales (Bond & Godfrey, 1997)

from work in aphasia

- Designed to rate impression of an interaction in TBI
Measure of skill in Supported Conversation (MSC)
- Support in conversation requires the communication partner to:

- How
- appropriate,

1.

Acknowledge competence (adult, shared)

- interesting (engaging),

2.

Reveal competence (modify language so TBI can understand and

express themselves)

- effortful,
- rewarding

Measure of Participation in Conversation (MPC)

- ..is the interaction as rated by independent observers

- Participation in conversation requires appropriate:

- ..rated on a reliable 9 point likert scale?

1.

Interaction (feel)

2.

Transaction (content)

Rated on a reliable, 9 point likert scale (0-4)

Goals for AS to be more normal again

Goals for AS to be more normal again

Goals for Mother: to communicate with him as an

adult child
- Slow down speech, pauses at phrase boundaries
- Ask one question at a time, wait for his response

- To be able to start conversations with family and friends

- Use simple questions

- To extend conversations

- Observe and respond to his nonverbal /verbal cues

- To share conversation i.e. 50:50 (esp. with mum)

- Avoid correcting / praising Tony in a teacher manner

- Develop new topics

- Signal when youd like to take a turn, holding turns

- Use a balance of questions AND comments

- Use less formal vocabulary and grammar

- Support his organisation of conversations, especially

planning tasks with cognitive supports

- Adopt a cool, calm and collected frame of mind in

difficult communication situations

- Use back channeling cues to acknowledge his points

- To provide information rather than testing questions

TBI express training program

TBI Express

Group + individual training for TBI JOINT group

[Link]

Group of 4-5 people with TBI & their communication partners

2 therapists
2.5 hr weekly group sessions (+ morning tea/social break)
1 hour weekly individual sessions
10 week program, divided into 7 modules
Manualised approach

(Togher et al., 2004; Ylvisaker, et al.,1998)

- Aim: more enjoyable and productive conversations

- Targeting common communication problems observed in interactions
- Collaborative and elaborative conversational strategies
- Enhancing / supporting communication of person with TBI
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Principles of TBI Express training

Three ways to have a good conversation

Practice in conversations and role plays

Use of immediate audio feedback

Collaboration

Use of observation sheets to guide self monitoring of performance

Daily homework practice expected between sessions, including regular
recordings of conversation at home

Elaboration

Practice encouraged in every day communication activities

Homework was reviewed at the beginning of each individual and group
session
Principles of neuroplasticity used intensive practice, repetition, salient,
meaningful communication environments

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.
[Link]
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.

Example from the manual: Collaboration

Collaboration means working together to help communication to happen effectively.

Review home practice and troubleshoot any issues (15 mins)

Aims

Outline session overview and aims (5 mins)

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

Collaborative style: role play collaborative and non collaborative styles

using handout (20 mins)

Objectives - at the end of the session you will be able to:

Collaborative intent: handout discussion and practice conversation (20

mins)

Define what is meant by collaborative communication style

Cognitive support: handout discussion and conversation practice (15

mins)

Contrast non collaborative communication styles with more positive alternatives

Use a positive collaborative style in interactions with your communication partner

Emotional support: handout discussion and practice conversation (15

mins)

Resources to bring

BREAK

Equipment

DVD player Digital video tape recorders

Handouts

ECP A4-1, ECP H4-1 to 4-7, ECP R4-1, ECP HW 4-1

Other

List of DVD titles, DVD of the Mythbusters

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Collaboration session plan

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COLLABORATION

Session plan: continued

Questions: Positive style: handout and discussion (15 mins)

We are doing this together, as a cooperative project

Collaborative turn taking: handout and discussion (15 mins)

When in conversation, this means that we intend to convey this message

to the other person. That is, we take turns, each having a go and helping
the other person. Conversation is more about shared meaning than
whether content is right or wrong alone. Collaboration is a way of sharing
the floor in a conversation, making sure that each person contributes as
much as they can in the situation, supporting the person with brain injury
to participate as much as possible.

Putting it all together: handout and discussion (40 mins)

Home practice for this week (5 mins)

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Collaborative

X Non collaborative

Shares information

Demands information

Confirms partners
contributions

Talks like a teacher

Shows enthusiasm

Corrects the person

Communicates respect

Fails to acknowledge
difficulties

Questions in a non
demanding, supportive
way

Lack of enthusiasm

Quiz like questions

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Example
E.g., collaborative methods could be used to plan a barbecue
Person with TBI says:

I want to have my BBQ at home

Less collaborative CP:

No. We cant have a big barbecue in our unit, well

have it at a community centre.

More collaborative CP:

It would be nice to have the BBQ at home.

I was thinking though, weve got lots of people
coming and our place is pretty small(see if this
cues an alternative)
Lets think of bigger places we could have it.

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 information when

needed

Doesnt give info when

needed; instead quizzes

Uses memory, organization

supports (calendars, photos,
diaries, books, notes)

Fails to use or encourage

cognitive supports at
appropriate times

Gives cues in a
conversational manner

Fails to give cues

Responds to errors by giving

correct information in a nonpunitive manner

Corrects in a punishing
manner and considers
accuracy more important
than the message

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30

Gives cues in a conversational manner

There are different kinds of questions that can be used to cue recall in
conversation:

EMOTIONAL
SUPPORT

Cast your mind back Create an image of the scene you are going to
talk about.

LACK OF EMOTIONAL
SUPPORT

Communicates respect Fails to communicate

for others concerns,
respect for others
perspectives and abilities concerns, perspectives
and abilities
Acknowledges

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

difficulties (Its hard to

get all these things in
order isnt it?)

Asking a specific question Asking a question that provides some

specific detail to prompt recall (e.g. Where was that place we went which
had the really delicious chocolate cake?)
Build up the picture Creating a detailed account of the event or scene
by extending upon the information provided by the other person

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Types of collaboration

Fails to acknowledge
difficulty of the task and
continues despite
difficulties
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What are ways you could use EMOTIONAL

SUPPORTS in these cases?
Trouble getting conversation started ___________________
Trouble finding the right word? ___________________
Difficulty remembering details? ___________________
Getting muddled or confused? ___________________
When person with TBI is frustrated? ___________________
When communication partner is frustrated? ___________________

Types of collaboration

QUESTIONS:
POSITIVE STYLE

QUESTIONS:
NEGATIVE STYLE

Questions in a nondemanding manner

Questions in a demanding
manner (quiz like)

Questions that share

information rather than test
memory

Questions in a nonsupportive manner (How are

you going to do that?)

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)

Elaboration and question asking

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

Introduces topics which

are not interesting to the
person

Add information to
help develop topics
Organises information

Session 7. Helpful Questions.

Using helpful questions, how avoid using negative, or testing questions.

Sessions 8-10. Improving skills and confidence.

Revision sessions to refresh and reinforce information learnt along with actual
practice of each technique. Session 10 also celebrates group members
achievements with lunch.

Makes connections
when topics change

Changes topic
frequently
Fails to make
connections from one
day to the next

Reviews what has

been said

NH&MRC Clinical trial

Question asking

Good questions

X Poor questions
3 arm trial which compares:

Open ended

Closed

True questions

Testing, quiz like

- About events where you

were not present

- Question asker already

knows the answer

- Feelings

- Testing performance,
memory

- Opinions

1. Treating communication deficits of the person with TBI

directly (TBI SOLO)
2. Training everyday communication partners (ECP) along
with the person with TBI (TBI JOINT)
3. A delayed treatment control group (CTRL)

10

Everyday communication partner (ECP)

participants

TBI Participants
44 participants with severe TBI (38 males, 6 females)
Recruited from Liverpool, Royal Ryde and Westmead Brain Injury
Units, Sydney, Australia

44 communication partners of person with TBI

- Mean age = 50 years (SD = 15.5, range = 17-79)

Mean age = 36 years (SD=14, range=18-68)

- Mean education = 13 years (SD = 2.7, 9-19)

Mean education = 12 years (SD=3, range=7-20 )

- 80% were female

Mean time post injury = 8 years (SD=7.2, range=1-25)

- 80% knew the person before the TBI

Mean PTA = 83.15 days (SD=61, range=6-182)

- The majority were partners or parents, however siblings and friends

also participated in the study

Study Participants
Allocated to
TBI JOINT - Communication partner treatment
n=14 ( 1 dropout = 13)

Treatment Communication Partner training

Group and individual training for TBI JOINT group
Group of 4-5 people with TBI & their communication partners
2.5 hr weekly group sessions (+ morning tea/social break)

TBI SOLO - Person with TBI alone treatment

n=15 ( 1 dropout = 14)
CTRL - Delayed treatment control
n=15 ( 1 dropout = 14)
93 % retention rate at post assessment and 87.5% retention at 6 mo f/up

ANOVA comparison across groups ns for:

Age, education
Time post onset, PTA
Cognitive-linguistic impairment (SCATBI)
ECP age
ECP education

1 hour weekly individual sessions for each pair

10 week program
Manualised approach: TBI Express
Interpersonal communication skills
Collaborative and elaborative conversational
strategies (Ylvisaker et al 1998)
Enhancing / supporting communication of
person with TBI/ question asking strategies
Treatment fidelity

11

Treatment TBI only training

Group and individual training TBI SOLO group

Group of 4-5 people with TBI

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

Training Program Communication Partners

Session 1: Introduction
Aims of training, group guidelines and home practice expectations established.

Session 2: TBI and communication

Training Program Communication partners

Session 6. Elaborative conversation

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.

Educational on TBI, cognition & communication

Session 7. Helpful Questions

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

Training collaboration where both the feel and information exchange are more equal,
shared and organised.

Explores use of helpful questions and how avoid using negative, or testing
questions.

Sessions 8-10. Improving skills and confidence

Revision sessions to refresh and reinforce information learnt along with actual
practice of each technique. Session 10 also celebrates group members achievements
with lunch.

12

Training program for people with TBI

Module 1 Introductions
Module 2 TBI and Communication
Module 3 Effective Communication
Session 1 Conversation Formulas
Session 2 Revision and Practise
Module 4 Starting and Participating in Conversations
Module 5 Extending Conversations
Module 6 Asking Questions
Module 7 Putting it all Together

49

Example from Module 3, Session 1 treatment

session
Communication gives us a sense of our identity.

50

Identity and metaphor

Ylvisaker, M., & Feeney, T. (2000). Reconstruction

of identity after brain injury. Brain Impairment, 1(1),
12-28.

Think about how you communicate with others.

What does your communication style portray to others? (E.g., That you are
fair, reasonable, enthusiastic, aggressive, silly, mature?)
How would you like to portray yourself to others?
Think of an example of someone you know (it could be someone you know
personally, or a celebrity, politician, leader, historical figure) who also
embodies these qualities.

Ylvisaker, M., McPherson, K., Kayes, N., & Pellett,

E. (2008). Metaphoric identity mapping: Facilitating
goal setting and engagement in rehabilitation after
traumatic brain injury, Neuropsychological
Rehabilitation, 18, 713 741.

Think of a famous person that you would like to be like.

Why do you want to communicate in this way?
If you successfully communicate in this way how will it make you feel?

51

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13

Module 3: Thinking about the context of

interactions

Module 3: Types of communication

How can we describe a conversation?

Communication is affected by the type of conversation that is happening.

Who? Who is participating? What is their relationship?

The different types of conversation each have a different structure.

Recount (telling about an event which happened in the past)

What? What is it about? What is the topic?

Anecdote (a funny story about something that happened to you or

someone you know)

Where? What situation are they in? What are the physical features?
When? What time of day, or stage of their life?

Narrative (telling about the plot of a movie or a book)

How? Are they communicating by speaking, writing or in another

way?

Opinion (what do you think about this topic)

Procedure (explaining about how to do something)

Why? What is the purpose of the communication? What job is being

done?

Chat (small-talk used to build social connection)

Description (telling about the features of an object, place or person)
What types of communication are easiest for you?
What types are more difficult?
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54

Example of homework tasks from Module 3

Task 1. Role play two conversations with a set formula

Plan and Rehearse a Conversation

Pick two conversations with a set formula that you commonly

Identify a conversation you will need to have with someone in

use (e.g. ordering food, getting a movie ticket, making an

the next week (e.g. asking to borrow something from someone,

appointment).

inviting someone to do something with you)

Situation for Conversation 1: ___________________________

Write out a plan of the main points you would need to cover in the

Situation for Conversation 2: ___________________________

conversation.

Record a role-play with your practice person for each of these

kinds of conversations.

Record a rehearsal of this conversation with your practice person

55

Example of homework tasks

56

14

Treatment fidelity

Outcome measures
Primary outcome measures (blinded)

Use of a treatment manual: TBI Express

- Adapted Kagan scales (Togher et al., 2010)

Collection of data on participants attendance rates: at least

80% attendance to be considered to have completed the
program

- La Trobe Communication Questionnaire (LCQ)(Douglas et al., 2000)

Secondary outcome measures

Bond and Godfrey global impression scales (Blinded)
Carer burden

Collection of data on completion of homework tasks

Qualitative interviews

Fully complete

Discourse analysis measures

Partially complete
Not completed

57

The Adapted Kagan scales for TBI Interactions

Primary outcome measure

Adapted Kagan scale (Kagan et al., 2001,2004; Togher et al, in

Scales ranged from 0 (no participation) through 2

(some) participation to 4 (full participation) in
conversation

press)
Measure of Participation in Conversation (TBI)

Inter-rater reliability scores for both the Adapted MPC

scales were excellent

level and quality of conversational participation

Ability to interact and socially connect (Interaction
scale)

(MPC: ICC = 0.84-0.89). Over 90% of ratings scored within 0.5

on a 9 point scale

Ability to respond to and/or initiate content

(Transaction scale)

Intra-rater agreement was also strong

(MPC: ICC = 0.81-0.92). Over 90% of ratings scored within 0.5
on a 9 point scale

videotaped interactions rated by 2 blind assessors

9-point Likert scales, presented as a range of 0 to 4 with 0.5 levels
for ease of scoring
59

58

(Togher et al., 2010, Aphasiology)

60

15

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

Initial analysis compared amount of change across the

3 groups with repeated measures ANOVA pre and post
treatment in purposeful and casual conversation
conditions

Interesting/engaging
Rewarding
on a 9 point scale, 0-4

Intention to treat analysis used

Social perception ability: The Awareness of Social Inference Test

(McDonald, Flanagan & Rollins, 2002)
Social participation: Sydney Psychosocial Reintegration Scale (Tate et al.,
1999)
Confidence and self esteem: Rosenberg Self Esteem Scale (Rosenberg,
1965)
Caregiver satisfaction: Modified Care Burden Scale (Machamer et al., 2002)
Discourse analysis measures
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62

RESULTS

Casual conversation: Interaction scale

No statistically significant differences between the three

groups at baseline on MPC ratings
Significant treatment effect measured on the MPC
Interaction scale in both casual conversation and
purposeful conversation conditions
i.e., the JOINT group improved relative to the other two
CC = Casual
conversation
63

64
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16

Purposeful conversation: Interaction scale

Results

Significant treatment effect was also found on the MPC

Transaction Scale in both casual conversation and
purposeful conversation conditions

PC = Purposeful
conversation

65

Casual conversation: Transaction scale

66

Purposeful interaction: Transaction scale

PC = Purposeful
conversation
CC = Casual
conversation

67

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17

And was it maintained over time?

Did the treatment work?

Yes!!

Yes !!

After treatment there were significant treatment effects found

for those who attended communication partner training

Effect was maintained at 6 month follow up

Person with TBI was judged to have better interactional skills

Communication partners improved in their ability to help the

i.e., The communication partner training group

improved relative to the other two groups

person with TBI communicate effectively

Conversations were rated as being more rewarding, less
effortful and more interesting

Post & Follow up treatment results

Post Ax:

AS indicated a 3 point improvement on LCQ (36)

ASs Mo reported a 1 point improvement* (57)
AS indicated that he perceived 11/30 behaviours had
improved while his Mo identified 24*
* Mo said didnt really know what I was rating last time..,I
was too easy last time, that wasnt right
Follow up: AS LCQ=38, with 13/30 improved, Mo LCQ=39
(18 point improvement), with 26/30 behaviours improved.

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18

Improved conversation skills for AS

Improved social life / regaining self identity

Mother: Hes also become more organised with a lot of his

thoughts, when youre having a conversation they used to be
random; when your having a conversation he jumps all over the
place and I have to bring him back to the topic Ill tell you the
truth I was confused most of the time. And when I asked a simple
question hed give me this long confusing answer and now hes
getting better at it so we have more understanding not just
between us but other people as well.

015_TBI: I found it nothing but beneficial. Nothing negative has

come out of it. Ive now regained my self, level of self
confidence. Ive regained my level of social standing, I used to
be scared to get involved in conversations but now I know how
to get into conversations, I know how to get into them properly
without being rude

Improved conversation skills for Mo

Mother: "Its been beneficial for me, now I don't talk as fast or
bombard him. Now I slow down and I put things clearly for him"

015_ECP: I feel number one that he has gained confidence and

has made more of a social life because of that confidence and
recently hes made a new friend which he hasnt done before.

Discussion
Change of mind set for Mother

Mother: Well number 1, I wanted him to have the independence

thats my drive with the recovery, and I wanted him as close to as
his was before the accident. Number two, I feel that this is his
body and mind he needs to be in control of it not me, its not
about me, its about him. If people want to know about him, talk
to him, I dont know whats going on in his mind. I dont know
how he feels, he can tell you if he learns how to communicate, he
can tell them and then I dont have to talk for him, often in front
of him too! Thats what I found embarrassing for him mainly, to
talk to him as if he wasnt there and I was standing next to him!
We can go shopping and if they ask me a question I say you can
ask him! And by talking to him it makes other people less afraid
to talk to him, and I think what was I so afraid about?!! He can
carry a conversation.

Training communication partners was more efficacious than

training the person with TBI alone
Success was due to key training principles including:
Communication being a collaborative and elaborative process (Ylvisaker
et al., 1998)
Training the ECP to reveal the competence of the disabled speaker
(Kagan et al., 2004)
Sensitively targeting behaviours of the ECP (eg test questions, speaking
for the person with TBI) led to a significant change in everyday
interactions

76

19

Discussion

Discussion
Training communication partners had advantages

Communication partners were challenged to change

THEIR OWN communication behaviours

Partners are cognitively intact and can therefore learn and

retain new information

Eliminating testing questions to which they already knew

the answer

Training partners led to higher compliance with homework

in the JOINT group when compared to the SOLO group

Reducing questions which checked the accuracy of the

person with TBIs contribution

Increased practice in between sessions supported the

principles of experience dependent neuroplasticity (Kleim &
Jones, 2008)

Speaking to the person with TBI as an adult and not a child

77

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

78

Research translation
TBI Express

[Link]
unity/tbi_express/

Awareness and education are often all that is needed

Can start small with one relevant situation in a persons
life and build from there

20

Research translation: manual, DVD,

website

82

Non collaborative behaviours

Giving him too many options without allowing him enough time to think
about the choices
Asking him to rely on his memory without giving cues
Testing his memory rather than helping the conversation to be interesting
or enjoyable
Correcting him in a punishing manner while making his errors obvious
rather than giving a natural conversational response
Talking to him like a teacher, including praising his ability to remember in a
condescending way
Lecturing him on correct behaviour rather than showing understanding
Taking a leadership role in conversation and stating her own plans rather
than allowing him to contribute.

21

Collaborative behaviours

Research translation

Asks questions that include information which help him remember

rather than putting pressure on him to remember
Gives cues in a conversational manner
Gives correct information conversationally and connects his incorrect
information to the correct answer to make his error less obvious
She contributes her opinions so that they are sharing equally in the
conversation
Invites him to share his opinions without putting pressure on him
Acknowledges his opinion even though she may not agree
She communicates respect for his concerns
She makes a suggestion about going to the shops but leaves it open
for him to agree or disagree
She guides him to organize his thinking and make a plan
86

Research translation : resources for

families

87

22

Summary

Conclusions

Training communication partners was more efficacious than

training the person with TBI alone

Training communication partners made a difference to the

conversational skills of people with TBI, and this led to a
change in the first impressions of strangers as measured by
the Adapted Kagan MPC scales.

Communication training for families led to improved

engagement in social activities, increased independence for
some people with brain injury
Provided the first link in re-establishing the social network of
the person with TBI
Training everyday communication partners is an important
complementary treatment for people with TBI and their families
to facilitate and promote improved communication outcome

Significant improvements have also been found in our other

primary outcome measure, the LCQ
Training everyday communication partners is an
important complementary treatment for people with TBI
and their families to facilitate and promote improved
communication outcomes

89

90

Where to from here?

Acknowledgements

Telehealth Assessment

AS and his mother:

and treatment using Skype

(Rachael Rietdijk)

For permission to present

their case. For their courage

Trialing the use of TBI Express

with people in outer urban, rural and remote areas

(Seeding funding from the Institute of Safety Compensation

and Recovery Research (VIC)

and enthusiasm for helping

Westmead Brain
Injury Unit

to improve skills of health

professionals so as to
improve outcomes for
people with TBI.

23

Evidence based practice and

traumatic brain injury
speechBITE [Link]
INCOG

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24

INCOG
INTERNATIONAL TRAUMATIC BRAIN INJURY
COGNITIVE REHABILITATION (INCOG) GUIDELINE

Cog Comm #1. Rehabilitation staff should recognize that levels of

communication competence and communication characteristics may
vary as a function of communication partner, environment,
communication demands, communication priorities, fatigue and other
personal factors (adapted from ABIKUS 2007, G51, p. 24;Royal College
of Physicians 2003, G70, p. 33).

The INCOG Guideline is the result of a thorough search,

review, and critical evaluation of currently published Clinical
Practice Guidelines (CPGs), and best evidence by a panel of
international experts comprising TBI cognitive rehabilitation
researchers and clinicians.

Cog Comm #2. A person with TBI who has a cognitive-communication

disorder should be offered an appropriate treatment program by a
speech-language pathologist (SLP) (adapted from ABIKUS 2007, G47,
p. 23).

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 #3. A cognitive-communication rehabilitation program should

take into account the persons premorbid native language, literacy, and
language proficiency; cognitive abilities; and communication style,
including communication standards and expectations in that individual s
culture (adapted from New Zealand Guideline Group 2006, 6.1.5, p. 97;
DeRuyter & Becker 1988).

INCOG Cog-communication guidelines

(Togher et al., in press)

INCOG Cog-communication guidelines

(Togher et al., 2014)
Cog Comm #6. Patients with severe communication disability should be
assessed for, provided with and trained in the use of appropriate
alternative and augmentative communication aids by suitably accredited
clinicians: speech language pathologists (for communication) and
occupational therapists (for access to devices, writing aids, seating etc.)(
(adapted from ABIKUS 2007, G46,50, p. 23-24; Royal College of
Physicians 2003;20 De Ruyter & Kennedy 1991).

Cog Comm #4. A cognitive-communication

rehabilitation program should provide the opportunity
to rehearse communication skills in situations
appropriate to the context in which the patient will
live, work, study, and socialize after discharge
(adapted from ABIKUS 2007, G49, p. 24).

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).

Cog Comm #5. A cognitive-communication

rehabilitation program should provide education and
training of communication partners (adapted from
ABIKUS 2007, G48, p. 23).
99

INCOG Cog-communication guidelines

(Togher et al., 2014)

100

25

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

Optimal Interventions for Community-Living Adults

More than 6 months after moderate-severe TBI
Without neglect, psychosis, or substance abuse

Group-Based Treatment
of Social Communication
Skills
(+/- Individual Treatment)
With Involvement of
Communication Partners

No
Ingredients:

Augmentative
Device
Assessment
and Training

CognitiveCommunication
Rehabilitation

*See Stroke Guidelines

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

From Togher et al., (2014) Journal of Head

Trauma Rehabilitation

101

References / further reading

1.

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.

For more information on social communication training studies in TBI see:

- Dahlberg, C. A., Cusick, C. P., Hawley, L. A., Newman, J. K., Morey, C. E., Harrison-Felix, C. L., et al.
(2007). Treatment Efficacy of Social Communication Skills Training After Traumatic Brain Injury: A
Randomized Treatment and Deferred Treatment Controlled Trial. Archives of Physical Medicine and
Rehabilitation, 88(12), 1561-1573.
- McDonald, S., Tate, R., Togher, L., Bornhofen, C., Long, E., Gertler, P., et al. (2008). Social skills
treatment for people with severe, chronic acquired brain injuries: A multicenter trial. Archives of
Physical Medicine and Rehabilitation, 89(9), 1648-1659.
104

26

References / further reading

4.

For more info on communication partner training in TBI / aphasia see:

-

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.

For more information on Collaboration and elaboration techniques see:

-

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.

For some video and additional information on Dr Ylvisakers techniques see:

[Link]

INCOG references

105

106

27