Journalof Speech and Hearing Research, Volume 39, S5-S 17, October 1996

Treatment Efficacy: Cognitive-

Communicative Disorders Resulting
From Traumatic Brain Injury in Adults

Carl A. Coelho
Southern Connecticut State University
New Haven

Frank DeRuyter
Duke University Medical Center Traumatic brain injuries (TBI) may result in a broad array of cognitive-communicative impair-
Durham, NC ments. Cognitive-communicative impairments are the result of deficits inlinguistic and nonlinguistic
cognitive functions. The speech-language pathologist functions as a member of the multidisciplinary
Margo Stein* team of professionals that collaboratively assess and treat individuals with TBI. The role of the
Health Care Consultant speech-language pathologist includes assessment of all aspects of communication, as well as
St. Louis, MO the communicative implications of cognitive deficits, and swallowing; treatment planning and pro-
gramming, as determined by the individual's stage of recovery; client and family training/counsel-
ing; and interdisciplinary consultation. The effectiveness of speech and language intervention for
specific cognitive deficits (e.g., attention, memory, executive functions) as well as general issues
of social-skills training and early intervention are illustrated by scientific and clinical evidence from
group-treatment and single-subject studies as well as case studies.

KEY WORDS: traumatic brain injury, cognitive rehabilitation, communication disorders,

intervention studies, treatment outcome

There is both scientific and clinical
evidence that individuals with cognitive-
communicative disorders resulting from
traumatic brain injury (TBI) benefit from
the services of speech-language patholo-
gists. This evidence is documented in
experimental research, program evalu-
ation data, and case studies. The pur-
pose of this paper is to summarize the
evidence pertaining to treatment efficacy
for cognitive-communicative disorders
secondary to TBI in adults.
Olswang (1990) has pointed out that
treatment efficacy is a broad term that
can address several questions related to
treatment effectiveness (i.e., Does treat-
ment work?), treatment efficiency (i.e.,
Does one treatment work better than
another?), and treatment effects (i.e., In
what ways does treatment alter behav-
ior?). Treatment efficacy studies have
used either group or single-subject ex-
perimental designs to answer these
questions; both methodologies are in-
cluded in this analysis.
Other sources of information, includ-
ing program evaluation data and case
studies, lend support to experimental
findings of treatment efficacy. Thus, such
information is included in this review. Al-
though program evaluation data cannot
answer questions about causal relation-
ships between the process and outcome
of treatment, they can document trends
intreatment for large patient/client popu-
lations, often defined by functional out-
comes. Finally, case studies offer more
individualized and patient/client-oriented
accounts of treatment benefit.
Definition of Cognitive-
Communicative Disorders
Communication is a process by which
information is exchanged (Davis, 1983).
The ability to communicate requires a

*Currently affiliated with the American Speech-Language-Hearing Association

1996, American Speech-Language-Hearing Association S5 0022-4685/96/3905.00S5

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 S6 Journalof Speech and Hearing Research
complex interaction between cognition
and language (Adamovich, 1991). Cog-
nitive skills include such processes as
attention, memory, reasoning, problem
solving, and executive functioning (i.e.,
self-awareness and goal setting, plan-
ning, self-directing/initiating, self-inhibit-
ing, self-monitoring, self-evaluation, flex-
ible thinking). Language skills involve
transmission of spoken, written, or non-
verbal messages (e.g., gestures, facial
expression) and reception of auditory,
printed, or nonverbal messages. Difficulty
or failure with any of these expressive-
receptive abilities or with any aspect of
cognition may result in a breakdown in
communication and thus the inefficient
exchange of information. Traumatic brain
injury may result in cognitive-communi-
cative impairments. Cognitive-communi-
cative impairments are those impair-
ments of communication related to
impairments of linguistic (e.g., syntax,
semantics, metalinguistic skills) as well
as nonlinguistic cognitive functions (e.g.,
attention, perception, and memory;
ASHA, 1987,1990).
Incidence and Prevalence
Data
Traumatic brain injuries result from
some form of trauma to the head. Such
injuries are classified as either penetrat-
ing (e.g., a gunshot wound) or closed
head injuries (e.g., resulting from sudden
acceleration/deceleration forces, such as
when a head strikes the dashboard of a
car) depending on whether or not the
meninges (the protective membranes
that cover both the brain and the spinal
cord) remain intact. A broader definition
of closed head injury also includes inju-
ries in which the meninges remain intact
but are disrupted-as seen, for example,
incases of shaken impact syndrome (i.e.,
child abuse in which a child is shaken
violently; Levin, Goldstein, Williams, &
Eisenberg, 1991). There are distinct dif-
ferences between penetrating and closed
head injuries in terms of type of deficits
and recovery, the discussion of which is
beyond the scope of this article (see
Grafman & Salazar, 1987, for a review).
Penetrating head injuries usually result
in focal lesions to specific areas of the
brain. Closed head injury may result in
focal lesions, diffuse axonal injury
(stretching, tearing, and shearing of
nerve fibers), or a combination of both.
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Although each type of injury may occur
in any region of the brain and result in
very different patterns of deficits, certain
regions of the brain are highly vulnerable
in closed head injury. For example, the
prefrontal region (front of the brain just
behind the forehead) and the limbic sys-
tem (located deep within the center of
the brain), as well as the connections
between the limbic system and the pre-
frontal region, are most vulnerable (Levin
& Kraus, 1994).
Kraus (1993) estimated that 500,000
individuals sustain head injury each year
(200 per 100,000 population). Of this
number, 200,000 die, 50,000 to 100,000
survive with significant impairments pre-
venting independent living, and more
than 200,000 suffer continuing sequelae
that interfere with daily living skills
(Gualtieri, 1988; Jennett, Snoek, Bond,
& Brooks, 1981; Kalsbeek, McLauren,
Harris, & Miller, 1981; Kraus, 1978). Of
the individuals who sustain TBI, nearly
twice as many males as females are in-
jured. The risk of TBI is higher among
males 15 to 24 years of age and the eld-
erly (over 75 years). Inthe United States,
trauma is the third leading cause of death
among individuals under the age of 35
(National Head Injury Foundation, 1983).
More than two thirds of all head inju-
ries are classified as mild. Definitions of
mild TBI vary; consequently, it has been
difficult to compare outcomes for such
individuals from different treatment cen-
ters. The American Congress of Reha-
bilitation Medicine (1993) has defined
mild TBI as traumatically induced physi-
ological disruption of brain function mani-
fested by at least one of the following:
(a) any period of loss of consciousness;
(b) any loss of memory for events imme-
diately before or after the injury; (c) any
alteration in mental state at time of injury
(dazed, confused, disoriented); or (d)
focal neurological deficits (may or may
not be transient) that result in loss of con-
sciousness for 30 minutes or less, an
initial Glascow Coma Scale score of 13-
15, and posttraumatic amnesia not
greater than 24 hours.
Effects of Cognitive-
Communicative Disorders
on Daily Life Activities
The effects of TBI on the survivor and
family are dependent, in large measure,
on the nature and severity of the injury.
39 S5-S17 October 1996
Because no two TBI cases are the same,
each injury yields a diverse constellation
of cognitive-communicative, physical,
and psychosocial deficits. The degree to
which these deficits impede the perfor-
mance of everyday activities depends in
part on the nature of the activities in
which a particular individual was en-
gaged before the injury. The impact of
TBI is perhaps best understood when
considered within the context of the
World Health Organization's proposed
classifications of impairment, disability,
and handicap (World Health Organiza-
tion, 1987). Impairment is defined as an
abnormality in physical or mental func-
tion-for example, cognitive disruption
such as decreased attention, which typi-
cally results from TBI. Disability refers to
a limitation in performance of an activity
because of an impairment; for example,
difficulty sustaining attention would influ-
ence the ability to read and follow instruc-
tions. Handicap is a loss of social role
function because of disability. Perhaps
the most disabling and handicapping ef-
fect of TBI is a reduced capacity to pur-
sue preinjury interests and daily activi-
ties at the same functional level. Such
disability exists along a broad continuum
that can range from requiring additional
time to complete tasks to near total de-
pendence on others for all basic needs.
Symptoms following mild TBI are quite
variable and may include difficulty con-
centrating under distracting conditions or
problems managing tasks involving mul-
tiple demands. Areas commonly dis-
rupted are attention, memory, and execu-
tive functioning. Mild TBI may also result
in word-finding difficulties, decreased
motivation, anxiety, depression, and irri-
tability (Levin, Eisenberg, & Benton,
1989; Sohlberg & Mateer, 1989a). These
deficits are present in spite of normal find-
ings on conventional diagnostic proce-
dures such as computerized tomography
and magnetic resonance imaging. Long-
term follow-up of patients with mild head
injury often reveals loss of jobs, divorce,
substance abuse, and generally disorga-
nized lives.
Alexander, Benson, and Stuss (1989)
note that in individuals with prefrontal
injury, linguistic skills are typically intact;
however, they may show the following
deficits: (a)disorganized or impoverished
discourse (receptively and expressively);
(b) awkward or inappropriate social in-
teraction (i.e., difficulty with pragmatic

dimensions of language, including diffi-
culty interpreting social cues); (c) difficulty
with abstract forms of language (e.g.,
abstract concepts, figures of speech,
irony, sarcasm); (d) difficulty with flexibil-
ity in linguistic processing (e.g., ambigu-
ity); or (e)difficulty with speed of process-
ing. Injuries to the limbic system as well
as the connections between the prefontal
and the limbic structures are also char-
acterized by generally intact linguistic
skills, but are associated with inefficient
learning of new information (including lin-
guistic information) and reduced control
over emotional responses.
Jacobs (1988) surveyed the families
of 142 survivors of severe TBI regarding
whether or not the survivor was indepen-
dent in a variety of behavioral skills. The
skill areas involved a range of abilities
(e.g., reading, writing, telling time, con-
centration, remembering, and orienta-
tion) and a range of complexity (e.g., for
reading: reads and recognizes directional
signs or reads books). Results indicated
that TBI had a significant impact on the
survivors' ability to independently per-
form a variety of daily living skills.
The impact of TBI on the family may
be equally devastating. Jacobs (1988)
noted that although many survivors of
severe TBI live with their families, they
do not work or attend school and are
dependent upon others for accomplish-
ing daily skills, both inside and outside
the home.
Role of the Speech-Language
Pathologist
The speech-language pathologist is
a member of the team of rehabilitation
professionals that collaboratively as-
sesses and treats individuals who have
sustained TBI (see Ylvisaker, 1994).
Speech-language pathologists assume
primary responsibility for the assessment
of all aspects of communication: hear-
ing screening (with referral for compre-
hensive audiologic assessment as
needed), spoken language (comprehen-
sion & production), written language
(reading & writing), cognitive-communi-
cative functioning (i.e., exploring the
communicative implications of impair-
ments in such areas as orientation, at-
tention, memory, reasoning, problem
solving, executive functions), speech pro-
duction (articulation, fluency, phonation,
and resonance), augmentative and alter-
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Coelho et al.: Treatment Efficacy in Cognitive-Communicative Disorders
native communication, as well as swal-
lowing. Upon completion of this assess-
ment the findings are interpreted, and a
prognosis and treatment recommenda-
tions are formulated. Treatment planning
includes collaboration with educational
and vocational specialists to enable the
TBI individual to succeed educationally
and/or vocationally.
Speech-language pathologists are
responsible for the establishment of treat-
ment programs aimed at decreasing the
effects of impairments in all aspects of emphasis on inclusionary placement and
speech, language, cognitive-communi-
cative functioning, and swallowing. The
treatment plan includes long- and short-
term objectives (reviewed on a regular
basis); information regarding frequency,
estimated duration, and type of service;
and follow-up or referral to other profes-
sionals as necessary. In addition,
speech-language pathologists help to
identify effective and functional supports
to enable cognitively disabled individu-
als to be as independent and successful
as possible. Such supports may include
cognitive prosthetic devices (e.g.,
memory logs), adjustment of work expec-
tations (by co-workers and employer),
changes in the work/classroom environ-
ment (e.g., allowing the individual to work
where distractions are minimal), modifi-
cation of teaching procedures to be con-
sistent with the individual's cognitive
strengths and weaknesses (e.g., elimi-
nation of time constraints, as in untimed
tests). Throughout the treatment planning
process the issue of context must be
carefully considered. Context refers to
both the content of what a particular in-
dividual needs as well as the setting or
physical environment that the individual
needs in order to function optimally.
Decontextualized treatment activities that
take place in artificial environments (set-
tings that are different from those the in- observed that helping TBI individuals to
dividual will encounter in the real world)
and that involve tasks the individual will
never be called upon to perform may not
constitute effective intervention (Klonoff,
O'Brien, & Prigatano, 1989; Lawson &
Rice, 1989; Singley & Anderson, 1989).
Treatment programs vary depending
on the stage of recovery (Adamovich,
Henderson, & Auerbach, 1985). In the
early stages of recovery the speech-lan-
guage pathologist directs efforts at elic-
iting and sustaining responses by the
patient/client. All sensory modalities may
be used, and the clinician must identify
S7
the best techniques for interacting with
the patient/client. In later stages of re-
covery, traditional cognitive rehabilitation
takes place. Individual and/or group treat-
ment may be supplemented by com-
puter-assisted treatment. To facilitate
carryover of treatment objectives to
nonclinical environments, contextu-
alization of treatment activities takes
place as soon as it is feasible. For ex-
ample, early return to work with a job
coach or educational intervention with an
support in that setting are methods to fa-
cilitate carry-over. Family or significant
other training/counseling, as well as in-
terdisciplinary consultation and dismissal/
discharge planning, also are ongoing.
Definition of Cognitive
Rehabilitation
Cognitive rehabilitation refers to a
treatment regimen aimed at increasing
functional abilities in everyday life by
improving an individual's capacity to pro-
cess and interpret incoming information.
Two approaches to cognitive rehabilita-
tion-restorative and compensatory-
have been described. The restorative
approach is based on the notion that
neuronal growth, and thus improvement
in function, is associated with repetitive
exercise of neuronal circuits. Incontrast,
the compensatory approach operates on
the assumption that certain functions
cannot be recovered; therefore, the de-
velopment of strategies to circumvent
impaired functions is the primary goal.
This conception of cognitive rehabilitation
suggests that "restoration" and "compen-
sation" are distinct phases of rehabilita-
tion such that compensatory strategies
are not implemented until restorative ex-
ercises have failed. However, it has been
become increasingly aware of their cog-
nitive needs and to be strategic in ap-
proaching cognitively demanding tasks
(i.e., using a "compensatory" approach)
is actually restorative; that is, this re-
stores the strategic, deliberate aspect of
cognitive processing. Therefore, it is in-
appropriate to contrast "restorative" and
"compensatory" as though they were not
overlapping approaches. Rather it has
been suggested that these approaches
should occur simultaneously in rehabili-
tation (M. Ylvisaker, personal communi-
cation, April 1995).
 S8 Journal of Speech and Hearing Research
Evidence of the Benefits of
Treatment
The literature on the efficacy of cog-
nitive rehabilitation has focused either
on the effects of general TBI rehabili-
tation programs (in which the services
of speech-language pathologists are
one component) or on specific interven-
tions for discrete deficits (e.g., atten-
tion and memory). Findings from sev-
eral studies concerned with both are
summarized below.
General RehabilitationPrograms
Rehabilitation programs consisting of
general interventions targeting cognitive
abilities and community-oriented groups
for facilitating appropriate social skills
have resulted in improved functioning in
subjects with TBI. That is, statistically sig-
nificant improvements on standardized
neuropsychological tests have been
noted following treatment (Prigatano et
al., 1984). For example, the effectiveness
of cognitive retraining for such abilities
as attention, memory, and problem- solv-
ing skills was investigated by Ruff, Baser,
Johnson, and Marshall (1989). Results
showed improvements for both a control
group of subjects who received training
in such areas as health and art and a
group of subjects who received cognitive
retraining. However, subjects who re-
ceived memory training showed improve-
ments beyond that of the control group.
Harrington and Levandowski (1987) also
showed statistically significant improve-
ment on posttest Luria-Nebraska Neuro-
psychological Battery scores after com-
munity-oriented group rehabilitation.
Improvements appeared on a variety of
neuropsychological functions, including
memory.
Somewhat mixed findings were re-
ported for a group of TBI individuals en-
rolled in a post-acute rehabilitation pro-
gram (Mills, Nesbeda, Katz, & Alexander,
1992). Although cognitive measures
were not affected by treatment, there
were significant improvements on vari-
ous functional measures reflecting im-
provements inhome, community, leisure,
and vocational activities. Follow-up at 6,
12, and 18 months demonstrated main-
tenance of treatment effects. Similarly,
Ruff and Niemann (1990) compared two
types of cognitive rehabilitation on
neuropsychological performance. One
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program used a general stimulation ap-
proach and the other a structured
remediation approach focused on atten-
tion, spatial integration, and problem
solving. Both treatments involved group
therapy. Following treatment, both groups
of subjects showed significant improve-
ments in cognitive function, suggesting
that treatment ina structured setting, with
a trained professional and psychosocial
group support, has positive effects on
cognitive functioning independent of the
particular method of treatment.
Attention
Several studies have reported improved
attention following treatment involving au-
ditory and/or visual modules (Ben-Yishay,
Piasetsky, & Rattock, 1987) and verbal
repetition (Malec, 1984). Success also has
been reported with computer-assisted at-
tention retraining (Ruff et al., 1994;
Sohlberg & Mateer, 1987). However, some
computer-assisted retraining programs
have led to significant gains in attentional
performance, without generalization of
treatment effects (Nieman, Ruff, & Baser,
1990). Finally, performance feedback
(Webster, McCaffrey, & Scott, 1986) and
reinforcement (Wood, 1986) also have
been shown to improve certain aspects of
some TBI subjects' attention skills. See
Table 1 for a summary of studies focused
on improving attention skills.
Memory
Some degree of memory dysfunction
is a consistent finding in most individu-
als following TBI. Consequently, numer-
ous studies have investigated the pos-
sible underlying nature of memory
dysfunction in this population. TBI pa-
tients/clients may have difficulty retriev-
ing information because of problems with
the encoding stage of memory that are
due to a decreased ability to generate
semantic associations (Levin & Goldstein,
1986) and visual imagery (Richardson,
1984). Therefore, a variety of mnemonic
training strategies have been developed
in an effort to enhance these associations
and images (Crovitz, 1979; Crovitz,
Harvey, & Horn, 1979; Gianutsos &
Gianutsos, 1979; Wilson, 1987). Several
studies also have investigated the effect
of simultaneous practice of multiple strat-
egies (Daniel, Webster, & Scott, 1986;
Fussey & Tyerman, 1985; Malec &
39 S5-S17 October 1996
Questad, 1983; Molloy, Rand, & Brown
as cited in Benedict, 1989; Ryan & Ruff,
1988). Details of these studies and oth-
ers appear in Table 2.
Although the findings of these reports
are encouraging, a problem common to
many memory-retraining approaches
and to cognitive rehabilitation programs
in general is that of generalization. Most
authors agree that after the treatment
situation is removed, spontaneous imple-
mentation of the learned skill is minimal
and many of the skills taught do not im-
prove functional, everyday memory
(Lawson & Rice, 1989; O'Connor &
Cermack, 1987; Parente & Parente-
Anderson, 1989; Schacter & Glisky,
1986). However, there are case studies
of memory interventions with TBI indi-
viduals in which successful generaliza-
tion and transfer of trained tasks has
been noted-for example, see Lawson
and Rice (1989) and Sohlberg and
Mateer's (1989b) report on the use a
memory book. Recently, also reported to
be successful is a computer-based mul-
timedia program for memory retraining
(Ruff et al., 1994).
Executive Functions
Difficulties with executive functions
are common afterTBI and are frequently
associated with damage to the frontal
and prefrontal cortex (Sohlberg, Mateer,
& Stuss, 1993). According to Lezak
(1982), executive functions comprise
those mental capacities necessary for
formulating goals, planning how to
achieve them, and carrying out the plans
effectively. Ylvisaker and Szekeres
(1989) note that following severe trau-
matic brain injury most individuals dem-
onstrate communicative deficits directly
attributable to disruption of executive
functions. They list a number of dimen-
sions of executive functioning in which
this dysfunction may occur, including (a)
self-awareness and goal setting, (b)
planning, (c) self-direction and initiation,
(d) self-inhibition, (e) self-evaluation,
and (f) flexible problem solving. It has
been suggested that problems with ex-
ecutive functions, more than any other
cognitive ability, determine the extent of
social and vocational recovery follow-
ing TBI (Sohlberg & Mateer, 1989a).
Self-monitoring procedures (Sohlberg,
Sprunk, & Metzelaar, 1988) and verbal
and visual feedback (Burke, Zencius, &
 Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders S9

TABLE 1. Summary of a sampling of treatment efficacy studies for deficits of attention resulting from TBI.

Study N Treatment focus Improvements/findings reported

Ben-Yishay, Piasetky, & 11 Orientation Remedial Module, five tasks Subjects progressed from impaired to
Rattock (1987) involving reception of visual and/or auditory normal range for all five tasks after training
stimuli and elicitation of simple visuomotor and at 6-month follow-up
responses
Malec (1984) 1 Practice with verbal repetition task Gains inselective attention noted during
conversation
Sohlberg & Mateer (1987) 4 Hierarchy of computer tasks for focused, Processing speed and vigilance
sustained, selective, alternating, and divided
attention
Ruff, Mahaffey, Engel, 15 Selected tasks tailored to individual's needs Performance on computer tasks, psycho-
Farrow, Cox, & Karzmark using THINKable (computer-based metric measures, and patient and observer
(1994) multimedia program developed by IBM) in ratings of everyday attention and memory
attention and memory behaviors
Niemann, Ruff, & Baser 29 Computer-assisted attention retraining Attention performance, but no generaliza-
(1990) tion of treatment effects (perhaps due to
frontal lobe dysfunction)
Webster, McCaffrey, & Scott 2 Reaction time practice with performance Reaction time performance
(1986) feedback
2
Wood (1986) Token reinforcement for selective attention Selective attention enhanced
Wood (1986) 4 Reinforced practice of attention tasks Gains noted on training tasks; no change
on other measures of attention

Weslowski, 1991) have been used intrain-
ing to improve certain aspects of execu-
tive functions (e.g., verbal initiation, re-
sponse acknowledgment) with reported
success (see Table 3 for summaries of
these and other studies). Other rehabili-
tation efforts aimed at improving execu-
tive functions in individuals with TBI re-
semble approaches to metacognitive
functioning that have been studied for
many years in the field of educational
psychology. That literature contains nu-
merous positive reports on the efffective-
ness of this type of intervention with
learning-disabled children and adoles-
cents. Caution certainly needs to be ex-
ercised inmaking cross-population infer-
ences; however, application of this
knowledge base to TBI rehabilitation has
been discussed by Pressley (1993) and
Meichenbaum (1993). The successful
incorporation of metacognitive processes
into treatment procedures for TBI pa-
tients with decreased planning ability and
poor self-control and self-monitoring
skills also has been reported by Cicerone
and Giacino (1992) and Cicerone and
Wood (1987).
Finally, other authors (Freeman,
Mittenberg, Dicowden, & Bat-Ami, 1992)
have described a memory remediation
program consisting of both compensa-
tory and executive training skills. The
executive strategy training was designed
to give individuals practice in the plan-
ning and analysis of task demands, in
selecting a strategy, in monitoring the
course of an activity, and in evaluating
the outcome of the activity. This practice
led to very encouraging outcomes, which
suggest that the functional memory skills
of certain TBI individuals can be im-
proved with treatment.
Social Skills Training
Social skills include a variety of abili-
ties (e.g., conversing, sharing, cooper-
ating, greeting others) that enable an in-
dividual to interact effectively with peers
and with others at home, in school, on
the job, and in other environments
(Ylvisaker, Szekeres, Haarbauer-Krupa,
Urbanczyk, & Feeney, 1992). An indi-
vidual who is "socially skilled" (a) has
knowledge of social rules, roles, and
routines; (b) accurately perceives and
interprets social cues; and (c) can regu-
late behavior (M. Ylvisaker, personal
communication, April 1995). These
abilities are vulnerable to disruption fol-
lowing TBI.
Several studies documenting the ef-
fectiveness of social skills training with
TBI individuals have appeared in the lit-
erature. For example, studies have de-
scribed the use of videotape feedback
(Brotherton, Thomas, Wisotek, & Milan,
1988; Helffenstein & Wechsler, 1982),
conversational skills training (Gajar,
Schloss, Schloss, & Thompson, 1984;
Schloss, Thompson, Gajar, & Schloss,
1985), treatments targeting the reduction
of inappropriate speech (Burke & Lewis,
1986; Giles, Fussey, & Burgess, 1988;
Lewis, Nelson, Nelson, & Reusink, 1988;
Zencius, Wesolowski, & Burke, 1990),
pragmatics (Ehrlich & Sipes, 1985), and
general social skills (Braunling-McMorrow,
Lloyd, & Fralish, 1986). These studies are
summarized in Table 4.
Community Re-Entry
Sustained community re-entry at the
highest level of productivity, indepen-
dence, and social adaptation for indi-
vidual patients/clients is the desired goal
of TBI rehabilitation (Malkmus, 1989).
Concerns have been expressed about

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 S10 Journal of Speech and HearingResearch
TABLE 2. Summary of a sampling of treatment efficacy studies for memory deficits resulting from TBI.
Study N Treatment focus
Crovitz, Harvey, &Horn 1 Mnemonic training strategies to improve
(1979) ability to generate semantic associations
Crovitz (1979) 1 Mnemonic training
Gianutsos &Gianutsos 1 Mnemonic training
(1979)
Wilson (1987) 8 PQRST strategy (preview material, ask
questions, read to answer questions, study
information, test for recall)
Wilson (1987) 36 Utility of three types visual imagery
strategies: rehearsal, clinician-generated,
and patient generated
Fussey & Tyerman (1985) 4 Simultaneous practice of multiple mnemonic
strategies: visual imagery and semantic
elaboration
Molloy, Rand, & Brown (as 1 Visual imagery and breaking down target
cited in Benedict, 1989) visual stimulus into component parts
Malec & Questad (1983) 1 Visual imagery and semantic story
elaboration
Daniel, Webster, & Scott 1 Visual imagery and self-instruction
(1986)
Ryan & Ruff (1988) 10 Visual imagery and group intervention
Ruff, Mahaffey, Engel, 15 Selected tasks tailored to patient's needs
Farrow, Cox, & Karzmark using THINKable (computer-based
(1994) multimedia program developed by IBM) in
attention and memory
Sohlberg & Mateer (1989b) 1 Compensatory memory book
Lawson & Rice (1989) 1 Executive strategy training to improve
spontaneous use of verbal recall strategy
WSTC: (What am I supposed to be doing?
Select a strategy. Try a strategy. Check the
strategy.)
the maintenance and generalization of remediation involves activities of high
treatment gains demonstrated inclinical interest to the individual (Huber &
settings. Such concerns have risen from Edelberg, 1993; Kneipp, 1991; Seaman,
research indicating that individuals with Roberts, Gilewski, & Nagai, 1993). Fur-
TBI often demonstrate chronic memory ther, such treatment enables clinicians
problems; and those with frontal lobe in- to identify skills that appear to be intact
juries, in particular, have extreme diffi- or functional in the sterile clinical set-
culty spontaneously executing trained ting, but are actually nonfunctional in a
strategies or techniques. home or work environment (Starch &
Functional gains are most easily Falltrick, 1990). Therefore, community-
achieved when cognitive remediation based intervention enables clinicians to
is carried out in the patient's/client's establish meaningful goals and to evalu-
home and community and when such ate progress. This is certainly consis-
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39 S5-S 7 October 1996
Improvements/findings reported
Ability to link stimulus words to visual
associations
Verbal recall
Word list recall
Recall of written paragraphs was superior
with PQRST versus simple rehearsal for
immediate and 30-minute recall conditions
All patients able to use clinician-supplied
cues, but only mildly imparied patients
could generate their own imagery cues
No improvement in memory noted
Increased recall scores
Gains on Wechsler Logical Memory; no
change in word association
Increased scores on paired associate recall
No gains in Wechsler Logical Memory;
other improvements dependent on degree
of memory impairment
Performance on computer tasks, psycho-
metric measures, and patient and oberver
ratings of everyday attention and memory
behaviors
Client learned to use system independently,
returned to work, lived in apartment with
minimal assistance despite deficits in
memory and new learning
Improved recall performance, maintenance
of strategy knowledge, and ability to
implement novel strategies
tent with the issue of the context of in-
tervention discussed above. Recently,
numerous case reports of treatment in-
tended to enhance daily living, educa-
tional, and vocational activities provided
by professionals who travel to the TBI
individual's home, school, or job have
cited positive results with regard to re-
turn to school (Blosser & DePompei,
1989; DePompei, & Blosser, 1987) or
gainful employment (Brantner, 1992;
Kneipp, 1991; Story, 1991; Wehman,
1991; Wehman et al., 1993).
 Coelho et al.: Treatment Efficacy in Cognitive-CommunicativeDisorders S11

TABLE 3. Summary of a sampling of treatment efficacy studies for deficits of executive functions resulting from TBI.

Study N Treatment focus Improvements/findings reported

Sholberg, Sprunk, &
Metzelaar (1988)
Burke, Zencius, & Weslowski
(1991)
Cicerone & Wood (1987)
Cicerone & Giacino (1992)
Cicerone & Giacino (1992)
von Cramon & Matthes-von
Cramon (1994)
Freeman, Mittenberg,
Dicowden, & Bat-Ami (1992)
1 Self-monitoring procedure for two aspects of
executive functions (verbal initiations and
response acknowledgment)
6 Verbal and visual feedback and various
checklists for improving social behaviors,
problem solving, and initiation
1 Three-stage training procedure for verbal
mediation followed by generalization training
with application to real-life problems
(decreased planning ability and poor self-
control)
6 Self-instructional technique using Tower of
London puzzle as training task
1 Error-monitoring involving self-recording of
errors and analysis of performance on
Tower of London puzzle
1 Generation of alternatives to a problem,
analysis of information, practice processing
multiple bits of information simultaneously,
and drawing inferences
6 Compensatory and executive training
Increase over baseline intarget communi-
cation behaviors during use of external
cues
Upon removal of checklists and feedback
trained behaviors were maintained
Gains noted post-training as well as
generalization
Improved performance
Improved self-monitoring ability
Successful use of technique by an
individual with severe frontal lobe dysfunc-
tion to the point that he was able to secure
supported employment
Significantly improved paragraph recall

Individual Differences Early Intervention to study the efficacy of cognitive reha-

When the effectiveness of cognitive
rehabilitation is evaluated, individual dif-
ferences among TBI patients/clients must
be considered. For example, Ryan and
Ruff (1988) noted that attention and
memory training was effective for a group
of 20 mildly to moderately impaired TBI
individuals, but not for a severely im-
paired group. At the very least, the cog-
nitive rehabilitation programs for more
severely involved patients/clients need to
be structured differently-with perhaps
more intensity, a greater degree of cue-
ing and reinforcement, and longer dura-
tion. In addition, without awareness of
deficits and motivation, it is difficult to
engage an individual with TBI in sus-
tained and effective treatment (Ben-
Yishay & Diller, 1993; Haarbauer-Krupa,
Szekeres, & Ylvisaker, 1985). Finally, in-
dividuals with TBI benefit from programs
of cognitive rehabilitation as long after
onset as 4 (Cicerone & Wood, 1987) to
6 (Boring, as cited in Benedict, 1989)
years. Therefore, time post-onset should
not preclude an individual's participation
in such a program.
bilitation. Applications of single-subject
The benefits of early aggressive reha-
designs to cognitive rehabilitation have
bilitation (including speech-language pa-
been described (Franzen & Harris, 1993;
thology services) during acute hospitaliza-
Gianutsos & Gianutsos, 1987; Wilson,
tion following TBI has been quantified by
1982) and reported by a number of in-
Mackay and colleagues (MacKay,
vestigators (Gajar et al., 1984; Schloss
Berstein, Chapman, Morgan, & Milazzo,
et al., 1985; Sohlberg & Mateer, 1987;
1992). Comparison of outcome data for a
Sohlberg et al., 1988).
group of TBI patients/clients who were in-
A multiple-baseline design is particu-
volved in the early intervention program
larly well suited for intervention research
with a second group who did not undergo
because it can deal with one of the pri-
this treatment indicated that the early in-
mary confounding variables in determin-
tervention group had significantly shorter
ing the effects of cognitive rehabilitation:
rehabilitation stays. Further, the early in-
spontaneous recovery. Only by demon-
tervention group was discharged at higher
strating greater improvement in a trained
levels of cognitive functioning and had a
skill area than in a nontrained skill area
significantly higher percentage of dis-
can intervention effects be inferred. The
charges to home versus extended care
multiple-baseline-across-behaviors de-
facilities. These findings are consistent with
sign allows for this sequential intervention
previous reports regarding the benefits of
and evaluation (Franzen & Harris, 1993).
early intervention (Cope & Hall, 1982).
Furthermore, the use of multiple-baseline
designs permits clinicians, in the context
Differentiating Treatment of a fee-for-service setting with high pro-
Effects and Spontaneous ductivity expectations, to assess the effi-
Recovery cacy of their treatment and appropriately
modify their interventions, online, without
Given the heterogeneity of TBI, it is the need for additional clinical time or cost
extremely difficult to use group designs (Sohlberg, Sprunk, & Metzelaar, 1988).

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 S12 Journalof Speech and Hearing Research 39 S5-S17 October 1996

TABLE 4. Summary of a sampling of treatment efficacy studies for social skills deficits reulting from TBI.

Study N Treatment focus Improvements/findings reported

Helffenstein & Wechsler
(1982)
Brotherton, Thomas,
Wisotzek, & Milan (1988)
Gajar, Schloss, Schloss, &
Thompson (1984)
Schloss, Thompson, Gajar, &
Schloss (1985)
Giles, Fussey, & Burgess
(1988)
Zencius, Wesolowski, &
Burke (1990)
Burke & Lewis (1986)
16 Role playing for interpersonal communica-
tion skills with videotape feedback
4 Individual therapy with role-playing and
videotape feedback for posture, speech
dysfluencies, self-manipulative behaviors,
and low frequency responding
2 Group discussions and role-played
conversations using feedback and self-
monitoring training
2 Heterosexual conversational interactions, to
increase giving compliments, asking
questions, and to decrease inappropriate
self-disclosures using self-monitoring
training
1 Conversational skills training to decrease
inappropriate behavior and tangentiality
using positive and negative reinforcement
1 Visual and verbal feedback to reduce
profanity
1 Behavior point system to decrease verbal
outbursts, interruptions, and nonsensical
talk
Gains instaff ratings of everyday behavior
and observer ratings of two interactions
3 of 4 clients maintained improvement at
1-year follow-up; most stable gains were in
nonverbal skills; verbal social skills were not
maintained at follow-up
Appropriate conversational responses
increased to normal range, but dropped
when training was discontinued
Compliments and questioning increased,
but self-disclosures did not decrease
Improvements in conversational skills
Profanity decreased inthree settings
Verbal outbursts and interruptions were
more responsive to treatment than
nonsensical talk

Lewis, Nelson, Nelson, &
Reusink (1988)
Ehrlich & Sipes (1985)
Braunling-McMorrow, Lloyd,
& Fralish (1986)
1 Various types of feedback (attention, Client responded best to verbal corrections
(anoxic) ignoring, verbal correction) to decrease
impulsive, disinhibited, and inappropriate
social behaviors
6 Pragmatic skills: nonverbal communication, Greater improvements noted for linguistic
conversation, repairing communication skills than nonlinguistic
failures, and narrative cohesion using role-
playing and videotape feedback
3 Situational social skills: compliments, social Improvements noted inappropriateness of
interaction politeness, criticism, confronta- mealtime social interactions, but no
tion, and questions and answers using generalization to other everyday social
hypothetical situations and gameboard behaviors

Summary of Program ceived speech-language pathology treat- Institute of Chicago-Functional Assess-

Evaluation Data
An intrinsic limitation of all data man-
agement systems currently available to
speech-language pathologists is that, at
present, they are not sophisticated or
sensitive enough to measure small in-
crements of functional change. It is with
this knowledge that retrospective out-
come data were obtained from five well-
established, fully accredited inpatient
rehabilitation programs throughout the
United States to determine whether any
trends in outcomes could be identified.
Each facility provided data for all of
their patients/clients with TBI who re-
ment in communication and cognition
and were discharged during a 12-month
period. A variety of commercially avail-
able and customized functional status
measures were used to determine out-
comes by the five reporting facilities.
These included the Functional Assess-
ment Measure (FAM, Santa Clara Valley
Medical Center, 1993), the Functional In-
dependence Measure (FIM, State Uni-
versity of New York at Buffalo, 1990), the
Patient Evaluation and Conference Sys-
tem (PECS, Harvey &Jellinek, 1979), the
Rancho Rehabilitation Outcome Evalu-
ation (RROE, Rancho Los Amigos Medi-
cal Center, 1993), and the Rehabilitation
ment Scales (RIC-FAS, Heinemann,
1993). The two consistent elements in
all outcome measurement systems were
that each used a 7-point rating scale and
that data were obtained on patients/cli-
ents at both admission and discharge.
Three of the facilities analyzed outcome
data by the amount of improvement as
determined by the average percentage
of gain in functional score. The remain-
ing two sites analyzed outcome data by
the average percentage of patients/cli-
ents who demonstrated functional im-
provement. The data provided by the fa-
cilities were collected during calendar
year 1992 or fiscal year 1992-1993 and

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included a total of 444 patients/clients.
Not all sites provided information on all
outcome measures. The data reported
indicate trends and reflect a weighted
average that is based on the total num-
ber of patients/clients for whom data
were available in each area.
All facilities reported length of stay
(LOS) information. The overall average
LOS, based on all 444 patients/clients,
was 46.3 days, with a range from 32.5 to
58.4 days across facilities. Variability in
LOS is most often associated with fac-
tors that include patient/client acuity and
cognitive status upon admission, num-
ber of co-morbidities, severity of physi-
cal involvement, medical complications,
age, and length of time from onset to re-
habilitation admission. These factors also
may affect the severity of the cognitive-
communication disorder. It is important
to note that the LOS data do not neces-
sarily reflect the actual need for or length
of speech-language treatment program
because clinicians traditionally have little
influence over LOS within the inpatient
rehabilitation setting.
Only four facilities reported data re-
lated to the discharge placements of their
patients/clients. Of the 345 reported dis-
charges, 83.5% (Range: 73.3%/96.2%)
were discharged home with or without
assistance; 10.7% (Range: 0%-20.0%)
were discharged to long-term care facili-
ties; and 5.8% (Range: 3.8%-9.0%) were
discharged to other facilities (e.g., acute
care settings) because of medical insta-
bility and did not return to the compre-
hensive rehabilitation program. The high
percentage of patients/clients receiving
speech-language pathology services
who returned to the community is con-
sistent with overall rehabilitation indus-
try discharge placement data.
Functional outcome data were avail-
able for 407 patients/clients in the ar-
eas of receptive and expressive lan-
guage (see Table 5). The amount of
improvement, as determined by the av-
erage percentage of gain in functional
score, involved a sample of 212 pa-
tients/clients. The data from the remain-
ing sample of 195 patients/clients were
analyzed by the average percentage of
functional improvement. With regard to
receptive language, an average gain of
over 16% in functional score was noted,
and an average of approximately 69%
of the patients/clients demonstrated
functional improvement. For expressive
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Coelho et al.: Treatment Efficacy inCognitive-Communicative Disorders S13
TABLE 5. Summary of program evaluation data for TBI patients receiving speech-lan-
guage pathology services from five inpatient rehabilitation facilities.
Treatment area Amount improvement Number patients improved
Average (%) Range (0%) Average (%) Range (%)
Receptive language 16.4 8.3-22.9 69.4 67-82.5
Expressive language 17.8 8.6-24.3 72.7 71-73
Speech production 9.7 7.7-12.6 71
Reading 10.3 7.3-14.9 88
Writing 11.3 6.9-18 77
Cognition 26.1 75
Note. Data on functional outcomes inthe areas of receptive and expressive language represent
407 patients: 212 were analyzed by amount of improvement and 195 by percentage of func-
tional improvement. The speech production data represent 377 patients. Inthe areas of reading
and writing, data represent 160 patients: for cognition, the data represent 217 patients.
language, an average gain infunctional bilitation contribute to variations in the
score of nearly 18% was reported, and trends reported. It is important to note that
an average of approximately 73% of the these findings have been limited to inpa-
patients/clients demonstrated improve- tient rehabilitation. Cognitive-communica-
ment. Regardless of measure, the great- tive intervention should be provided as
est functional improvement was seen in necessary along the continuum of care.
the area of expressive language across Data related to the treatment benefits in
all facilities. both the pre- and postrehabilitation set-
Four facilities reported speech pro- tings are needed.
duction data from a total of 377 patients/ With the continued advancement in
clients. The average gain in functional data management systems, the outcome
score was approximately 10%. An aver- measurement tools used will become
age of 71% of the patients/clients dem- increasingly refined and sensitive in the
onstrated improvement. monitoring of functional change. These
In the areas of reading and writing, systems will allow examination of follow-
three facilities reported data from 160 up as well as cost/benefit data and their
patients/clients. For reading, average relationship to outcomes and will allow
gain in functional score of over 10% was further examination of the long-term ef-
noted, and an average of 88% of the fects of speech-language pathology ser-
patients/clients exhibited improvement. vices in the rehabilitation process for
For writing, an average gain of approxi- patients/clients with TBI.
mately 11% in functional score was re-
ported, and 77% of patients/clients dem-
onstrated improvement. Summary
Finally, in the area of cognition, only Several treatment efficacy studies of
two facilities reported data, which repre- cognitive rehabilitation were reviewed.
sented 217 patients/clients. An average Results of these studies indicate that
gain in functional score of 26% was there are a number of treatment tech-
noted, and 75% of the patients/clients niques that have been successfully ap-
demonstrated cognitive improvement. plied to deficits of attention, memory,
These trends inthe functional improve- and executive functions in various TBI
ment of cognitive-communicative abilities patients/clients. The heterogeneity of
(amount of functional improvement, num- TBI patients/clients prevents the appli-
ber of patients/clients who improved, and cation of a generic treatment approach
the high percentage of patients/clients dis- for this population. For those patients/
charged home) support the notion that a clients with more severe cognitive-com-
period of intensive inpatient rehabilitation municative deficits, treatment may be
is beneficial for cognitive-communicative more effectively directed toward the
deficits secondary to TBI. All such factors development of compensatory strate-
as the amount and rate of recovery, gies such as use of memory aids (e.g.,
premorbid abilities and status, and cogni- appointment book, alarm watch, or a
tive level at the time of admission to reha- detailed daily schedule). In those indi-
 S 14 Journalof Speech and HearingResearch 39 S5-S17 October 1996

viduals with profound deficits, treatment
may best be focused on environmental
modifications or the arrangement of per-
manent support systems (e.g., training
family members/significant others to
prompt patient/client during activities of
daily living) (Depompei & Williams,
1994; Story, 1991). Single-subject mul-
tiple baseline designs are well suited for
studying the efficacy of these ap-
proaches to cognitive rehabilitation.
Interventions directed at specific cog-
nitive deficits are important; neverthe-
less, clinicians must address broader is-
sues of social skills retraining, timing of
treatment during recovery, treatment lo-
cation and its effectiveness (e.g., hospi-
tal, home, school, work). The benefits of
early intervention were also stressed.
The treatment efficacy findings for TBI
patients/clients were also supported by
data from five rehabilitation facilities that
used various program evaluation sys-
tems. Although none of these data man-
agement systems are particularly sensi-
tive to small incremental changes, the
data revealed that functional gains were
realized in receptive and expressive lan-
guage, speech production, reading, writ-
ing, and cognition for TBI patients receiv-
ing speech-language treatment.
The cost/benefit of cognitive rehabili-
tation is supported by the findings of
Aronow (1987), who noted that inpatients
receiving rehabilitation services returned
to productive living at the same rate as a
less severely injured group who had not
received treatment. Furthermore, when
patients/clients with similar severity of
disabilities were compared, those who
had received rehabilitation had better
average cost outcomes than those not
receiving rehabilitation services.
Finally, future research regarding the
treatment efficacy of cognitive-commu-
nicative disorders resulting from TBI
should address the following issues: (a)
representativeness of the TBI subjects
(i.e., most of the studies completed to
date have excluded very severely im-
paired individuals or those with marked
behavioral problems), (b)identification of
subgroups of TBI patients with very spe-
cific rehabilitation needs, and (c) broad-
ened criteria for a successful outcome
from cognitive rehabiliation to include
quality-of-life indices such as family re-
lationships and leisure activities.
Acknowledgments
The authors wish to thank those individu-
als who provided feedback on the initial draft
of this article: Brenda L.B.Adamovich, Roberta
DePompei, Danese Malkmus, McKay Moore
Sohlberg, and (inparticular) Mark Ylvisaker for
his extensive comments. Cynthia Thompson
and two anonymous reviewers provided sev-
eral excellent suggestions for revising an ear-
lier version of this article.
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Background
Kreutzer, Wehman, Conder, and Morrison (1989) reported
success with TBI patients/clients. One individual, a man in
his thirties, sustained a moderate head injury in a motorcycle
accident. Within one month post-injury he had recovered
physically but continued to demonstrate significant problems
with memory, attention, reasoning, and organization, as well
as difficulty controlling his temper. He subsequently had to
give up his free-lance photography and college teaching;
instead he turned to painting and home renovation. A major
problem for this individual was organizing his work schedule.
He often took more jobs than he could handle and received
many complaints from customers about delays in job
completion.
Treatment
The clinician established a plan to improve the timeliness of
his work by using a log that listed each job, the expected
duration of the job, and projected completion date. In addition,
new jobs were accepted and scheduled on a tentative basis
and only finalized after consulting with his wife, estimating
completion times liberally, and working on one job at a time.
Outcome
This process relieved a great deal of the man's stress.
Eventually he completed his master's degree, and although he
continued to work part-time as a contractor he resumed free-
lance photography and began looking for part-time teaching
positions. He and his clinician were also working on organiza-
tional strategies intended to improve his teaching skills.

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Contact author: Carl A. Coelho, PhD, De-
partment of Communication Disorders, South-
ern Connecticut State University, 501 Cres-
cent Street, New Haven, CT 06515-1355.
Email: coelho_c@scsu.ctstateu.edu