We are pleased to welcome Marsha Jo Hershman, M.A., CCC-SLP, as our guest 
host for the SLP chat on Monday, January 17, 2005. She will be addressing
Traumatic Brain Injury (TBI).

Marsha Jo Hershman, M.A., CCC-SLP, is currently a Cognitive Therapist
with PsychDynamics where she works in the diagnosis and treatment of
patients with traumatic brain injuries.  She is an Adjunct Professor
at Rowan University, Glassboro, NJ, where she teaches courses in Public
Speaking, Linguistics, and Interpersonal Communication.  Ms. Hershman
is also an Adjunct Professor at Camden County College, Blackwood, NJ,
where she teaches courses in Fundamentals of Speech and Public Speaking.  
Ms. Hershman has given numerous presentations regarding traumatic brain
injury, voice, and presentations skills.

Additional resources provided by our guest host may be found at the
bottom of this transcript page.

<Robin> Welcome!  We are chatting tonight about the topic of Traumatic Brain Injury
          (TBI) with guest host Marsha Jo Hershman, M.A., CCC-SLP.
<Robin> Marsha, please define TBI and give us some background info.
<Marsha Hershman, CCC-SLP> I'll give you the definition from IDEA.
<Marsha Hershman, CCC-SLP> TBI is defined as an acquired injury to the brain caused by an
          external physical force, resulting in total or partial functional disability or
          psychosocial impairment, or both, that adversely affects a child's educational performance.
<Marsha Hershman, CCC-SLP> The term applies to open and closed head injuring resulting in impairments
          in one or more areas, such as cognition, language, memory, attention and reasoning.
<Robin> I am assuming that the definition is the same if you are dealing with adults, but perhaps
          affecting their work performance.
<Marsha Hershman, CCC-SLP> It's pretty much the same minus the educational aspect.
<Robin> What is the incidence of TBI?
<Marsha Hershman, CCC-SLP> There are about 2 million TBI's each year...
<Marsha Hershman, CCC-SLP> that's one every 15 seconds
<Rose> Wow that's a lot!
<Marsha Hershman, CCC-SLP> Every 5 minutes someone dies from a head injury
<Robin> what is the main cause of TBI?  Motor vehicle accidents?
<Marsha Hershman, CCC-SLP> 51% are motor vehicle accidents (MVA)
<Marsha Hershman, CCC-SLP> 21% falls
<Marsha Hershman, CCC-SLP> 12% assaults & violence
<Marsha Hershman, CCC-SLP> 10% sports and recreation
<Susan> interesting
<Robin> How soon after the trauma you can initiate the evaluation?
<Marsha Hershman, CCC-SLP> That really depends on their physical condition...as soon as they are
          medically stable, they should be evaluated.
<Robin> Tell us about the evaluation of TBI.
<Marsha Hershman, CCC-SLP> Well, they're going to need a neuropsychological evaluation first.
<Robin> What is a neuropsychological evaluation exactly?
<Marsha Hershman, CCC-SLP> A traditional neuro psychological evaluation usually includes measurement of the
          following functions: mood & behavior changes, cognitive abilities, language abilities, memory & learning,
          intelligence (verbal & performance), executive functioning, academic/achievement, abstract reasoning &
          concept formation, fine motor control & speed, sensory & perception, effort & motivation, personality
          inventory, & psychosocial factors.
<Robin> Who performs this eval?
<Marsha Hershman, CCC-SLP> It's done by a neuropsychologist.
<Robin> Does the neuropsychologist then order the speech/language eval?
<Marsha Hershman, CCC-SLP> Yes...with their information, the SLP can then get down to specifics.
<becky> Well, I am relatively new to the field and have only seen one TBI patient.  When she came to me she
          was a little over a month post MVA (Motor Vehicle Accident) and was alert but unresponsive.  she had
          a  tube so Ijust did a small bedside and then referred for an MBS because she never had one done. 
          Other than that I just checked her visual tracking, gestures, auditory comprehension, etc.  She had
          no language.
<Marsha Hershman, CCC-SLP> With a mild TBI, I use Cognitive Symptom Checklists filled out by the patient
          and with a little more involvement, I usually use the RIPA (Ross Information Processing Assessment).
<becky> If there's more language deficits do you use the BDAE (Boston Diagnostic Aphasia Examination)?
<Marsha Hershman, CCC-SLP> Yes...if the neuropsychologist hasn't given it already.
<Marsha Hershman, CCC-SLP> I've worked with several who use it, so it saves me the time.
<Robin> What do you use to evaluate the very low functioning patient?
<Marsha Hershman, CCC-SLP> Often I use any aphasia test that seems appropriate.
<Marsha Hershman, CCC-SLP> Mild TBI seems to be harder to work with.
<Robin> So between the checklists, the RIPA and BDAE, you can make your evaluation.
<Marsha Hershman, CCC-SLP> That usually covers everything.
<Robin> What types of behaviors/deficits do you usually see in TBI patients?
<Marsha Hershman, CCC-SLP> Cognitive communication & language, memory, comprehension, especially learning
          new info, short attention span, concentration, distractibility, expressive language skills, organization,
          planning and decision making, judgment and reasoning, flexibility, studying and academic skills
<Rose> That's a long list!
<Robin> How do you address these areas in therapy?
<Marsha Hershman, CCC-SLP> I think therapy should be fun, so I use a lot of games.
<Marsha Hershman, CCC-SLP> I always make sure I give them the rationale, so they at least know it's work.
<Marsha Hershman, CCC-SLP> There are a lot of computer games for logic/problem solving.
<Marsha Hershman, CCC-SLP> They're also good for eye-hand coordination, visual scanning and processing.
<Marsha Hershman, CCC-SLP> I also use a lot of word games...Scrabble, Boggle, Overturn, Upwords, etc.
<Robin> What would you do, for example, to address attention span and distractiblilty?
<Marsha Hershman, CCC-SLP> For attention span, I might use a problem solver like Rollem in which they have to
          get points by dropping balls down a maze-like screen
<Rose> What is Rollem?
<Marsha Hershman, CCC-SLP> It's a computer game similar to Boloball, if you know that one.
<becky> I have a pretty severe TBI patient who is just starting to verbalize more.  She's pretty apraxic and makes
          mostly vowel sounds, yeah, and no.  She has said "hello" on the phone and I've been trying to do automatics,
          when we're counting to ten she can now say " one two, eight, nine and ten".  My problem is I don't know if I
          should keep working on this, because of her apraxia she has a very hard time imitating and I just got her to
          produce /m/ on Friday.  She is three months post MVA and I'm not sure if I should keep working on speech or
          if I should go the AAC device route.
<becky> She's come so far from a PEG tube to eating regular food with thin liquids and from being in a wheelchair
          to walking everywhere that I hate to give up on the speech.
<Robin> How old is your patient?
<Marsha Hershman, CCC-SLP> Becky, how frustrated does she get?
<becky> She is 46 and she does get frustrated so I switch things frequently. We have also been practicing the
          alphabet for writing and she gets all of it except four letters now.
<Marsha Hershman, CCC-SLP> I would work until I exhausted all therapy options before going AAC.
<Marsha Hershman, CCC-SLP> She's still fairly young and can probably go further.
<becky> Her auditory comprehension isn't that great, she needs visual models to follow directions.
<becky> Should I stick with automatics and syllable production?
<becky> I've tried singing too but that didn't work.
<Marsha Hershman, CCC-SLP> I would try to make therapy as meaningful as possible.
<Marsha Hershman, CCC-SLP> If it means something to her, she might be more motivated, even with impaired auditory
****PLEASE EXPAND WITH MORE EXAMPLES IF YOU CAN <Robin> Marsha, can you give a specific example?
<becky> For example, work on words that have meaning to her, like her son's name or favorite foods?
<Marsha Hershman, CCC-SLP> Yes...that's what I mean.
<Marsha Hershman, CCC-SLP> The automatics can work for you.
<becky> The apraxia really makes things difficult because sounds like /k/ aren't visible so a mirror doesn't work
          and her auditory comprehension isn't very good and it's so difficult for her to imitate. I feel stuck.
<Marsha Hershman, CCC-SLP> Use the hand to the throat like they do with the hearing impaired...get her to feel it.
<Marsha Hershman, CCC-SLP> Apraxia is always difficult...it's frustrating for you and the patient.
<becky> Thank you for the tips!
<Robin> How about sentence completion with words that have meaning to her?
<becky> She can't do that either
<Marsha Hershman, CCC-SLP> Hopefully something will work soon.
<Robin> I wish we could think of something else for you to use with your patient, Becky.
<Marsha Hershman, CCC-SLP> It can get depressing working with younger patients like her who seem to be at a standstill.
<Marsha Hershman, CCC-SLP> Hang in there!
<becky> That's okay, I'm hopeful since she is vocalizing more now than before (even though many are not meaningful)
          and she's had so many gains in other areas.
<Robin> Marsha, what other types of strategies do you use in therapy, for example, when addressing memory?
<Marsha Hershman, CCC-SLP> For memory, I can get back to games and use concentration type activities.
<Marsha Hershman, CCC-SLP> But some good strategies are also in order...
<Marsha Hershman, CCC-SLP> There's nothing wrong with prosthetic devices for memory...sticky notes, date books, etc.
<Marsha Hershman, CCC-SLP> It's also important to minimize distractions.  It makes it easier to process information.
<Rose> Any tips on improving comprehension?
<Marsha Hershman, CCC-SLP> Again, it's important to eliminate distractions in the environment.
<Marsha Hershman, CCC-SLP> Frequent repetition or a tape recorder can help, as well.
<Marsha Hershman, CCC-SLP> When I try to teach my students how to take notes, I suggest putting everything into
          their own words.
<Marsha Hershman, CCC-SLP> Self questions also help, as well as relating new information to what you already know.
<Robin> Marsha, is there anything else you would like to tell us about working with patients with TBI?
<Marsha Hershman, CCC-SLP> Well, with the mild TBI patients, they may not be aware of or admit to the extent of
          their symptoms until they attempt to return to normal functioning.
<Marsha Hershman, CCC-SLP> Mild TBI is often overlooked when there are obvious physical injuries.
<Rose> That is very true...how do you deal with that?
<Marsha Hershman, CCC-SLP> Once they find that they have difficulty returning to their "old life", it's fairly easy
          to convince them they need help.
<Marsha Hershman, CCC-SLP> Again, games can come in handy.
<Marsha Hershman, CCC-SLP> I use a simple game of Pick-up-sticks on the computer to show them what they can do.
<Marsha Hershman, CCC-SLP> We work to increase speed with accuracy.
<Marsha Hershman, CCC-SLP> It's really a helpful tool and games keep me interested, too!
<Robin> The idea of using games is a good one.....likely keeps the patient interested without getting too frustrated.
<Dave_G.> Marsha-I am seeing a patient who feels she doesn't deserve to be helped - since she ran a red light.
<Marsha Hershman, CCC-SLP> That's a tough one....some psychological counseling is in order, but you might try going
          in the back door by using games...like I said, it's a fun way to get people into therapy.
<Dave_G.> Thanks Marsha
<Marsha Hershman, CCC-SLP> No problem..good luck
<Robin> We have been chatting for close to an hour...Marsha, thank you for sharing your expertise with us!
<Marsha Hershman, CCC-SLP> It's been a pleasure
<madeline> This was very informative.
<Susan> Thank you for sharing this information
<Rose> thank you
<Robin> Thank you again!  We appreciate you sharing your time and expertise. Thank you all for coming!
<Marsha Hershman, CCC-SLP> Thanks a lot...have a good evening everyone.


Clinical and Neuropsychological Aspects of Closed Head Injury
John T.E. Richardson

Mild Traumatic Brain Injury:  A Therapy and Resource Manual
Betsy S. Green, Kristin M. Stevens, Tracey D. W. Wolfe

The Source for Executive Function Disorders
Susanne Phillips Keeley

Cognitive Reorganization:  A Stimulus Handbook
Sharon Holloran-Hitzel and Elizabeth Bressler-Richardson

Advanced Communication Exercises
Kathryn J. Tomlin

Cognitive-Linguistic Improvement Program
Deborah Ross-Swain

Functional Memory Manual
Jean Elbaum, Peggy Kramer, Deborah Benson, Carrie Dulaski