Clinician
Amy L. Dubey, OTR, CBIS, IMP, SIPT
Organization
Abby D Center, Comprehensive Neuro-Cognitive Communication Recovery Services, Traverse City, MI
Presenting Problems
- Not staying on task
- Unable to recall information
- Unable to write simple letters/emails concisely
- Distracted by visual and auditory information while performing tasks
- Poor visual motor skills (tracking, scanning, VOR)
- Poor organizational skills at home and in workshop
- Poor physical, visual and auditory endurance (fatigues quickly and easily throughout the day)
Therapeutic Goals
Improve auditory and visual memory; increase endurance and overall energy level; improve integration of multi-sensory information; strengthen focus/concentration ability.
Background
“Tom” is a 52 year-old male who had been involved in two different auto accidents and is diagnosed with a Mild Traumatic Brain Injury (MTBI). The first auto accident was in 2001 and the second was in 2008. He had received skilled therapies in 2001: Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (SLP).
He was the owner of a construction company for many years and has not returned to work since his last accident. Tom has been in rehabilitation for several years with hopes of returning to work; however, his cognitive deficits prevent him from doing so. There are no significant physical limitations that prevent him from working. Currently, he is 11 years post his first accident.
iLs Program
The iLs Concentration and Attention Program (40 one-hour sessions) was completed over a three-and-ahalf month period. Some of the iLs sessions were performed in the clinic and others were done at home. This allowed him to increase the frequency to more than the two times a week he was in clinic.
Other Interventions
Tom has been receiving OT and SLP services from the Abby D Center in February. He receives one hour of OT and one hour of SLP two times every week. He did receive OT and SLP after his first auto accident from another rehabilitation company. It was after his second auto accident that he began attending the Abby D Center.
Primary OT goals were to increase his endurance with visual processing, auditory processing, and multisensory processing. His visual and auditory memory skills were low, recalling only three items with 100% success. Any visual or auditory task lasting more than five minutes would cause severe physical and cognitive fatigue/exhaustion.
Mid-program Report by Client and Spouse
Improvements:
- Improvement in temper at home
- Recognizing others are around and being more considerate to others
- Feels his brain is getting clearer – less overwhelmed
- Able to prioritize activities in terms of importance
- “I know when to ask for help now and when to stop”
- Improved ability plan things out ahead of time
- Can consider other scenarios
- Decrease in crying
Areas client desires more improvement:
- Formulating what to say out loud quickly
- Staying on topic
- Staying on track and complete tasks/projects
- Coordinating left and right sides of body working together
- Processing speed with activities
Client Comments Post-program
- “I can now turn wrenches without turning my body to be right in front of it.” (He was unable to figure out which way to turn a wrench if he was not directly in front of it. He was a builder and mechanically inclined prior to the injury.)
- Can stay on task now while others are in the room.
- Can stay on task longer (hours) and complete the tasks he started.
- Able to work on two tasks at the same time, such as waiting for the glue to dry and move on to removing a tire and then able to go back and complete the gluing tasks. He used to completely forget to get back to the gluing task.
- When working on his car this week he had to wait for some sealer to dry and he went and worked on laying out his lumber. He was able to keep track of tasks and returned to his car task when the sealer was done. He never would have returned back to the task, without a prompt from someone.
Pre- and Post-Program Test Scores
Test of Auditory Processing Skills:
The Test of Auditory Processing Skills (TAPS-3) is an individually administered assessment of auditory skills necessary for the development, use, and understanding of language mostly use in academic and everyday activities. Norms are provided for ages 4 years – 0 months through 18 years -11 months. Although Tom is older than 18 years he should have scored 18+ years on all initial testing.
Pre and Post iLs TAPS-3 Scores. Scores in ( ) denote Pre iLs
| Subtests | Raw Score | Age Equivalent | Percentile |
| Word Discrimination | (32 / 32) 32 / 32 |
(18+ years) 18+ years |
(75%) 75% |
| Phonological Segmentation | (34 / 35) 35 / 35 |
(18+ years) 18+ years |
(50%) 75% |
| Phonological Blending | (18 / 35) 31 / 35 |
(7 years 6 months) 18+ years |
(9%) 75% |
| Number Memory Forward | (13 / 32) 17 / 32 |
(6 years) 9 years 2 months |
(1%) 9% |
| Number Memory Reverse | (10 / 32) 18 / 32 |
(9 years 2 months) 18+ years |
(9%) 63% |
| Word Memory | (21 / 30) 21 / 30 |
(15 years) 15 years |
(25%) 25% |
| Sentence Memory | (28 / 56) 29 / 56 |
(12 years 7 months) 13 years 5 months |
(25%) 25% |
| Auditory Comprehension | (26 / 32) 30 / 32 |
(12 years 7 months) 18+ years |
(50%) 75% |
| Auditory Reasoning | (15 / 34) 32 / 34 |
(10 years 9 months) 18+ years |
(9%) 75% |
SCAN-3 for Adolescents & Adults – Test for Auditory Processing Disorder
The SCAN-3 is an individually administered battery of tests designed to identify auditory processing disorders. The American Speech-Language Hearing Association defines Auditory Processing Disorder as a deficiency in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following skills:” (R.W. Keith, SCAN-3 manual, 2009. Pearson, Inc.)
- Sound localization and lateralization
- Auditory discrimination
- Auditory pattern recognition
- Temporal aspects of audition, including: temporal resolution, masking, integration and ordering
- Auditory performance with competing acoustic signals
- Auditory performance with degraded acoustic signals
Pre- and Post- iLs scores. The ( ) scores denote Pre-iLs scores.
| Test | Description | %Ranking | Scaled Score | Ranking |
| Gap Detection | This screening test measures the ability to detect brief gaps of variable durations (measured in ms) between tone pairs. | (Pass) Pass |
||
| Auditory Figure Ground 0 dB | This test is used to assess the ability to process speech in the presence of background noise at the 0 dB signal-to-noise ratio. This is used as a screening test and as a diagnosis test. | (9%) 37% |
(6 / 19) 9 / 19 |
(Borderline) Normal |
| Competing Words-Free Recall | This test is used to assess the ability to process competing speech signals presenting a monosyllabic word to each ear simultaneously. The examinee is instructed to repeat both words in any order. This test is used for screening and supplementary assessment. | (16%) 84% |
(7 / 19) 17 / 19 |
(Normal) Normal |
| Filtered Words | This diagnostic test is used to assess the ability to process distorted speech by presenting monosyllabic words low-pass filtered at 750 Hz. | (37%) 95% |
(9 / 19) 15 / 19 |
(Normal) Normal |
| Competing Words – Direct Ear | This diagnostic test is used to assess the ability to process competing speech signals by presenting a monosyllabic word to each ear simultaneously. The examinee is instructed to repeat both words in a prescribed order and scoring reflects the prescribed order. | (5%) 16% |
(5 / 19) 7 / 19 |
(Borderline) Normal |
| Competing Sentences | This diagnostic test is used to assess the ability to process competing speech signals by presenting pairs of unrelated sentences in the right and left ears. The examinee is instructed to repeat the sentence heard in one ear. | (1%) 75% |
(3 / 19) 12 / 19 |
(Disordered) Normal |
| Auditory Figure Ground +8 dB & 12 dB | These supplementary tests are used to assess the ability to process speech in the presence of background noise at +8 dB and +12 dB signal-to-noise ratios. | (9% & 16%) 63% & 37% |
(6 / 19 &7 / 19) 11 / 19 & 9 / 19 |
(Normal) Normal |
| Time Compressed Sentences | This supplementary test is used to assess the ability to process degraded speech by presenting sentences that have been time compresses at 60% | (.1%) 37% |
(1 / 19) 9 / 19 |
(Disordered) Normal |
Ear Advantage Summary Pre iLs program scores:
| Test | RE Score | – | LE Score | = | EA | Typical | Cumulative Prevalence |
| Auditory Figure Ground 0 |
9 |
– |
12 |
= |
-3 |
No |
10% |
| Competing Words – Free Recall |
13 |
– |
11 |
= |
2 |
Yes |
0% |
| Filtered Words |
17 |
– |
14 |
= |
3 |
No |
15% |
| Competing Words – Direct Ear RE |
9 |
– |
4 |
= |
5 |
No |
5% |
| Competing Words – Direct Ear LE |
12 |
– |
10 |
= |
2 |
Yes |
0% |
| Competing Sentences |
27 |
– |
22 |
= |
5 |
No |
5% |
| Auditory Figure Ground +8 dB |
18 |
– |
18 |
= |
0 |
Yes |
0% |
| Auditory Figure Ground +12 dB |
18 |
– |
19 |
= |
-1 |
No |
15% |
| Time Compressed Sentences |
21 |
– |
24 |
= |
3 |
No |
5% |
Ear Advantage Summary Post iLs program scores:
| Test | RE Score | – | LE Score | = | EA | Typical | Cumulative Prevalence |
| Auditory Figure Ground 0 |
13 |
– |
14 |
= |
-1 |
Yes |
0% |
| Competing Words – Free Recall |
17 |
– |
16 |
= |
1 |
Yes |
0% |
| Filtered Words |
20 |
– |
19 |
= |
1 |
Yes |
0% |
| Competing Words – Direct Ear RE |
11 |
– |
10 |
= |
1 |
Yes |
0% |
| Competing Words – Direct Ear LE |
14 |
– |
13 |
= |
1 |
Yes |
0% |
| Competing Sentences |
35 |
– |
35 |
= |
0 |
Yes |
0% |
| Auditory Figure Ground +8 dB |
20 |
– |
19 |
= |
1 |
No |
15% |
| Auditory Figure Ground +12 dB |
19 |
– |
19 |
= |
0 |
Yes |
0% |
| Time Compressed Sentences |
28 |
– |
30 |
= |
-2 |
No |
5% |
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
The RBANS is a short assessment that when administered can assist in measuring cognitive decline in adults with neurological injury or disease (stroke, head injury, Alzheimer’s, and dementia). There are 12 subtests that make up the assessment. Five cognitive areas are focused on: Immediate Memory, Visuospatial/Construction, Attention, Language, and Delayed Memory. This test has two record forms available (Form A and Form B) for retesting. Form A was used Pre iLs and Form B was used Post iLs for this client.
Pre and Post iLs program scores (Pre iLs used Record Form A and Post iLs used Record Form B) are shown below. Scores in ( ) denote Pre iLs scores.
| Immediate Memory | Visuospatial Memory | Language | Attention | Delayed Memory | Total Score | |
| Index Score |
(97) |
(109) |
(99) |
(94) |
(111) |
(102) |
| Confidence Interval 95% |
(87 – 107) |
(96 – 122) |
(88 – 110) |
(83 – 105) |
(99 – 123) |
(95 – 109) |
| Percentile |
(42%) |
(73%) |
(47%) |
(34%) |
(77%) |
(55%) |
| Ranking |
(Average) |
(Average) |
(Average) |
(Average) |
(High Average) |
(Average) |
Pre and Post iLs program scores are reported here. Items in ( ) are the Pre iLs scores.
|
|
Description of Test Items |
Client’s Performance |
| Immediate Memory | ||
| List Learning | A list of 10 semantically unrelated words is orally presented, and the examinee is asked to recall as many words as he can. This is repeated over 4 learning trials. | (Trial #1: 5 / 10) (Trial #2: 6 / 10) (Trial #3: 5 / 10) (Trial #4: 6 / 10) Trial #1: 4 / 10 Trial #2: 6 / 10 Trial #3: 8 / 10 Trial #4: 9 / 10 |
| Story Memory | A short story is orally presented and the examinee is asked to retell the story from memory. The same story is presented a second time, and the examinee is again asked to retell the story from memory. | (Trial #1: 7 / 12) (Trial #2: 11 / 12) Trial #1: 10 / 12 Trial #2: 11 / 12 |
| Visuospatial/Construction | ||
| Figure Ground | The examinee is shown a multipart geometric drawing and is asked to make an exact copy while drawing remains on display | (Trial #1: 18 / 20) Trial #1: 19 / 20 |
| Line Orientation | The examinee is presented with a drawing that consists of 13 equal lines radiating out from a signal point to form a semicircular fan shaped pattern. All lines are numbered (1 – 13). Below this drawing are two lines that match two lines from the array above. The examinee is asked to identify which two lines they match. Ten trials are given, with different sets of test lines on each trial. | (Trial #1: 19 / 20) Trial #1: 20 / 20 |
| Language | ||
| Picture Naming | The examinee is presented with a series of pictured objects and is asked to name each one. A semantic cue is provided only if an object is obviously misperceived. | (Trial #1: 10 / 10) Trial #1: 10 / 10 |
| Semantic Fluency | The examinee is given one minute to name as many exemplars as possible from a given category (Record Form A: fruits and vegetables) (Record Form B: animals in a zoo) | (Trial #1: 22 / 40) Trial #1: 19 / 40 |
| Attention | ||
| Digit Span | The examiner reads a string of digits and asks the examinee to repeat the digits in the same order. The length of the digit string increases by one each trial. | (Trial #1: 9 / 16) Trial #1: 10 / 16 |
| Coding | The examinee is presented a page filled with rows of boxes with a number from 1 to 9 above each box (in random sequence), and a blank space below the number. At the top of the page is a key with unique, simple, geometric shapes beneath each of the numbers, 1 through 9. Using the key, the examinee is asked to fill in the number corresponding to each shape, for as many boxes as the examinee can complete in 90 seconds. | (Trial #1: 46 / 89) Trial #1: 48 / 89 |
| Delayed Memory | ||
| List Recall | The examinee is asked to recall the list of 10 words learned in the List Learning subtest. | (Trial #1: 6 / 10) Trial #1: 8 / 10 |
| List Recognition | The examinee is read 20 words (10 target, 10 distractors) and asked to indicate whether each word was on the word list. | (Trial #1: 19 / 20) Trial #1: 20 / 20 |
| Story Memory | The examinee is asked to retell the story they learned earlier. | (Trial #1: 10 / 12) Trial #1: 11 / 12 |
| Figure Recall | The examinee is asked to draw the figure shown earlier from memory. | (Trial #1: 19 / 20) Trial #1: 18 / 20 |
Conclusions and Recommendations
Tom has made significant changes in his cognitive performance within just three-and-a-half months. He is 11 years post his first head injury and he is greatly pleased with his results. His wife, case manager and therapist have also noted his changes. During initial testing (pre-iLs) Tom fell asleep during the SCAN-3 test. He made it through the first three tests and then actually fell asleep during the fourth test and had to be woken up. His auditory endurance was very poor at that time. During the post testing of the SCAN-3 he completed the entire SCAN-3 test without fatigue setting in.
Tom would like to continue to work on the following:
- Memory
- Social skills
- Attention and endurance
- Speaking and writing skills
This therapist recommends Tom continue working on memory capacity skills as seen on the results of the TAPS pre-and post-testing. He has increased from a capacity of five digits with extreme fatigue (50% success) to a capacity of six-to-seven with little fatigue (the numbers are out of sequence). In addition, Auditory Figure Ground (AFG) has improved but he would benefit from more work. This increased skill would assist him with social and work conversations that take place in public areas and/or hearing information from the radio and television accurately.*
Recommendation: the iLs Reading and Auditory Processing Program (R/AP) to support auditory processing skills. Further discussion will take place with Tom, his physician, case manager, and therapist to determine further therapeutic intervention.
The following pre- and post- iLs program tests can be viewed by clicking here:
- SCAN-3 for Adolescents & Adults – Test for Auditory Processing Disorder
- The Test of Auditory Processing Skills (TAPS-3)
- Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Dr. Minson’s Comments
This case beautifully illustrates that improvements in cognitive and emotional brain function can be achieved even 11 years post Mild Traumatic Brain Injury (MTBI). This case, and many others I have personally treated, disproves the commonly held opinion among many physicians that the brain cannot improve its function beyond two years post head injury. The belief that further recovery is unlikely beyond 18-24 months post-injury is still firmly entrenched in the medical profession.
A few comments regarding the changes pre- and post-testing: The improvements in digit span may reflect improved attention and concentration rather than improved auditory processing. The remarkable improvement in phonological blending is likely due to both improved attention and auditory processing. The dichotic tests of Competing Words (CW) and Competing Sentences (CS) is another matter: CW is a test of divided attention where the CS test is a test of directed attention, and they are also measures of inter-hemispheric communication. Therefore, the robust improvements in these measures confirm improved cognitive flexibility, attention and communication between right and left hemispheres.
The improvement in List Learning is interesting in that his performance improved with repetition; repetition did not improve his performance prior to iLs. Again, a sign of improved overall brain function since this skill calls upon multiple brain areas to work together. Thus, it will be important for him to continue to use repetition as a cognitive strategy to improve his memory. Finally, the improved Compressed Sentences Test indicates an increase in speed of processing. Slow processing speed is one of the hallmarks of MTBI. Thus, the improvements from iLs and OT demonstrate improved overall brain function at both sub-cortical and cortical levels of processing.
*Addendum: It is essential that this gentleman get a hearing test from an audiologist. Based on the history and testing, it is very likely that he has a sensori-neural hearing loss particularly in high frequencies. Given his work in construction, the presence of a noise induced hearing loss can be expected and would explain his difficulty hearing in public areas and trouble hearing TV and radio. I agree that the R/AP program can help, particularly with continuing to improve concentration and energy, but it will not help the hearing problems nor the results on the AFG that I think are due to hearing loss.
For advanced practitioners, recall the case “Lover of Music”: An individualized listening program using the iLs Pro, as taught in the Advanced Training, may be indicated once the audiogram has been received.
