Memory and Traumatic Brain Injury: Assessment and Management Practices of Speech-Language Pathologists

PURPOSE

Memory impairments are among the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with traumatic brain injury (TBI). Memory and learning are also critical for rehabilitation success and broader long-term outcomes. Speech-language pathologists (SLPs) play a central role in memory management for individuals with TBI across the continuum of care. Yet, little is known about the current practice patterns of SLPs for post-TBI memory disorders. This study aims to examine the clinical management of memory disorders in adults with TBI by SLPs and identify opportunities to improve post-TBI memory outcomes.

METHOD

SLPs from across the continuum of care were recruited to complete an online survey. The survey assessed key practice areas specific to memory and memory disorders post-TBI, including education and training, knowledge and confidence, and assessment and treatment patterns.

RESULTS

Surveys from 155 SLPs were analyzed. Results revealed that TBI-specific training remains low in the field. Respondents varied in their practice patterns in assessing and treating memory disorders. Most SLPs do not appear to have access to appropriate standardized assessments to measure unique forms of memory. Respondents also reported a range of barriers and opportunities to advance memory outcomes following TBI and provided suggestions of areas in which they would like to see more basic and clinical research.

CONCLUSIONS

These findings establish a baseline of the current practices for clinical management of memory impairment in adults with TBI by SLPs. Improved opportunities for clinician training, the development of a single tool to assess multiple forms of memory, better access to existing memory assessments, and implementation of evidence-based interventions promise to lead to improved memory outcomes for individuals with TBI.

The Value of Patient Registries to Advance Basic and Translational Research in the Area of Traumatic Brain Injury

The number of individuals affected by traumatic brain injury (TBI) is growing globally. TBIs may cause a range of physical, cognitive, and psychiatric deficits that can negatively impact employment, academic attainment, community independence, and interpersonal relationships. Although there has been a significant decrease in the number of injury related deaths over the past several decades, there has been no corresponding reduction in injury related disability over the same time period. We propose that patient registries with large, representative samples and rich multidimensional and longitudinal data have tremendous value in advancing basic and translational research and in capturing, characterizing, and predicting individual differences in deficit profile and outcomes. Patient registries, together with recent theoretical and methodological advances in analytic approaches and neuroscience, provide powerful tools for brain injury research and for leveraging the heterogeneity that has traditionally been cited as a barrier inhibiting progress in treatment research and clinical practice. We report on our experiences, and challenges, in developing and maintaining our own patient registry. We conclude by pointing to some future opportunities for discovery that are afforded by a registry model.

Heterogeneity Is a Hallmark of Traumatic Brain Injury, Not a Limitation: A New Perspective on Study Design in Rehabilitation Research

Purpose In both basic science and intervention research in traumatic brain injury (TBI), heterogeneity in the patient population is frequently cited as a limitation and is often interpreted as a factor reducing certainty in the generalizability of research findings and as a source of conflicting findings across studies. Historically, much of TBI research in rehabilitation and cognition has relied upon case-control studies, with small to modest sample sizes. In this context, heterogeneity is indeed a significant limitation. Here, however, we argue that heterogeneity in patient profiles is a hallmark characteristic of TBI and therefore cannot be avoided or ignored. We argue that this inherent heterogeneity must be acknowledged and accounted for prior to study design. Fortunately, advances in statistical methods and computing power allow researchers to leverage heterogeneity, rather than be constrained by it. Method In this article, we review sources of heterogeneity that contribute to challenges in TBI research, highlight methodological advances in statistical analysis and in other fields with high degrees of heterogeneity (e.g., psychiatry) that may be fruitfully applied to decomposing heterogeneity in TBI, and offer an example from our research group incorporating this approach. Conclusion Only by adopting new methodological approaches can we advance the science of rehabilitation following TBI in ways that will impact clinical practice and inform decision making, allowing us to understand and respond to the range of individual differences that are a hallmark in this population.

Traumatic brain injury in the acute care setting: assessment and management practices of speech-language pathologists

PRIMARY OBJECTIVE

To characterize current knowledge, beliefs, confidence, and practice patterns of acute care speech-language pathologists (SLPs) in assessing and managing cognitive-communication disorders following traumatic brain injury (TBI).

RESEARCH DESIGN

We developed an online survey to learn more about current TBI knowledge and practice patterns of acute care SLPs, with the goal of establishing a baseline upon which changes in SLP training and practice standards may be measured.

METHODS AND PROCEDURES

We distributed the survey to 1800 SLPs in 18 states via postal mail, in addition to posting it to relevant online groups. One hundred and eighty-two practicing acute care SLPs responded to the survey.

MAIN OUTCOMES AND RESULTS

Respondents were highly variable in their training and knowledge about TBI, their beliefs about cognitive-communication rehabilitation, and their practice patterns in assessing, managing, and communicating about TBI during the acute stage of injury.

CONCLUSIONS

These results highlight the need for more consistent training about cognitive-communication deficits during and after graduate school, as well as the development of sensitive, specific, and standardized assessment tools, education protocols, and shared language for describing patients with TBI along the continuum of care.

An intracranial mass causing tumor-induced osteomalacia (TIO): Rapid and complete resolution of severe osteoporosis after surgical resection

Tumor-induced osteomalacia (TIO) is a rare disease in which patients suffer from fractures and progressive disabling bone pain and muscle weakness. TIO is caused by the hypersecretion of Fibroblast Growth Factor 23 (FGF23) from rare neoplasms of mesenchymal origin. This case report describes a 29-year-old male with 2 years of low back/hip pain, gait changes, proximal muscle weakness, and multiple stress fractures. Bone densitometry was remarkable for severe osteoporosis, hypophosphatemia was seen on routine labs, and advanced labs demonstrated an "inappropriately normal" FGF23 level. A 68Ga-DOTATATE scan and MRI showed a 1.3 × 1.1 × 1.0 cm intracranial mass. The patient underwent tumor resection by Neurosurgery. Shortly after, laboratory levels normalized, and the patient's symptoms improved drastically. This case exemplifies the notion that TIO can be caused by FGF23 levels within normal limits, the role of 68-Ga DOTATATE imaging for establishing a diagnosis, and that these tumors can arise anywhere-even intracranially. We also review current surgical and nonsurgical treatment options, as well as emerging novel therapeutics.

Semantic Memory and the Hippocampus: Revisiting, Reaffirming, and Extending the Reach of Their Critical Relationship

Since Tulving proposed a distinction in memory between semantic and episodic memory, considerable effort has been directed towards understanding their similar and unique features. Of particular interest has been the extent to which semantic and episodic memory have a shared dependence on the hippocampus. In contrast to the definitive evidence for the link between hippocampus and episodic memory, the role of the hippocampus in semantic memory has been a topic of considerable debate. This debate stems, in part, from highly variable reports of new semantic memory learning in amnesia ranging from profound impairment to full preservation, and various degrees of deficit and ability in between. More recently, a number of significant advances in experimental methods have occurred, alongside new provocative data on the role of the hippocampus in semantic memory, making this an ideal moment to revisit this debate, to re-evaluate data, methods, and theories, and to synthesize new findings. In line with these advances, this review has two primary goals. First, we provide a historical lens with which to reevaluate and contextualize the literature on semantic memory and the hippocampus. The second goal of this review is to provide a synthesis of new findings on the role of the hippocampus and semantic memory. With the perspective of time and this critical review, we arrive at the interpretation that the hippocampus does indeed make necessary contributions to semantic memory. We argue that semantic memory, like episodic memory, is a highly flexible, (re)constructive, relational and multimodal system, and that there is value in developing methods and materials that fully capture this depth and richness to facilitate comparisons to episodic memory. Such efforts will be critical in addressing questions regarding the cognitive and neural (inter)dependencies among forms of memory, and the role that these forms of memory play in support of cognition more broadly. Such efforts also promise to advance our understanding of how words, concepts, and meaning, as well as episodes and events, are instantiated and maintained in memory and will yield new insights into our two most quintessentially human abilities: memory and language.

Cross-Situational Statistical Learning of New Words Despite Bilateral Hippocampal Damage and Severe Amnesia

Word learning requires learners to bind together arbitrarily-related phonological, visual, and conceptual information. Prior work suggests that this binding can be robustly achieved via incidental cross-situational statistical exposure to words and referents. When cross-situational statistical learning (CSSL) is tested in the laboratory, there is no information on any given trial to identify the referent of a novel word. However, by tracking which objects co-occur with each word across trials, learners may acquire mappings through statistical association. While CSSL behavior is well-characterized, its brain correlates are not. The arbitrary nature of CSSL mappings suggests hippocampal involvement, but the incremental, statistical nature of the learning raises the possibility of neocortical or procedural learning systems. Prior studies have shown that neurological patients with hippocampal pathology have word-learning impairments, but this has not been tested in a statistical learning paradigm. Here, we used a neuropsychological approach to test whether patients with bilateral hippocampal pathology (N = 3) could learn new words in a CSSL paradigm. In the task, patients and healthy comparison participants completed a CSSL word-learning task in which they acquired eight word/object mappings. During each trial of the CSSL task, participants saw two objects on a computer display, heard one novel word, and selected the most likely referent. Across trials, words were 100% likely to co-occur with their referent, but only 14.3% likely with non-referents. Two of three amnesic patients learned the associations between objects and word forms, although performance was impaired relative to healthy comparison participants. Our findings show that the hippocampus is not strictly necessary for CSSL for words, although it may facilitate such learning. This is consistent with a hybrid account of CSSL supported by implicit and explicit memory systems, and may have translational applications for remediation of (word-) learning deficits in neurological populations with hippocampal pathology.

The effect of repetition on pronoun resolution in patients with memory impairment

Referring to things in the world - that woman, her idea, she - is a central component of language. Understanding reference requires the listener to keep track of the unfolding discourse history while integrating multiple sources of information to interpret the speech stream as it unfolds in time. Pronouns are a common way to establish reference. But due to their impoverished form, to understand them listeners must relate features of the pronoun (e.g., gender, animacy) with existing representations of potential discourse referents. Successful referential processing seems to place demands on memory. In a previous study, patients with hippocampal amnesia and healthy participants listened to short stories as their eye movements were monitored. When interpreting ambiguous pronouns, healthy participants demonstrated order-of-mention effects, whereby ambiguous pronouns are interpreted as referring to the first-mentioned referent in the story. By contrast, memory-impaired patients exhibited significant disruptions in their ability to use information about which character had been mentioned first to interpret pronouns. Repetition of the most salient information is a common clinical recommendation for improving pronoun resolution and communication in individuals with memory disorders (e.g., Alzheimer's disease) but this recommendation lacks an evidentiary basis. The present study seeks to determine whether the pronoun resolution performance of hippocampal patients can be improved, by repetition of the target referent, increasing its salience. Results indicate that patients with hippocampal damage demonstrate improved processing of pronouns following repetition of the target referent, but benefit from this repetition to a significantly smaller degree compared to healthy participants. These results provide further evidence for the role of the hippocampal-dependent memory system in language processing and point to the need for empirically tested communication interventions.

Knowledge and learning of verb biases in amnesia

Verb bias-the co-occurrence frequencies between a verb and the syntactic structures it may appear with-is a critical and reliable linguistic cue for online sentence processing. In particular, listeners use this information to disambiguate sentences with multiple potential syntactic parses (e.g., Feel the frog with the feather.). Further, listeners dynamically update their representations of specific verbs in the face of new evidence about verb-structure co-occurrence. Yet, little is known about the biological memory systems that support the use and dynamic updating of verb bias. We propose that hippocampal-dependent declarative (relational) memory represents a likely candidate system because it has been implicated in the flexible binding of relational co-occurrences and in statistical learning. We explore this question by testing patients with severe and selective deficits in declarative memory (anterograde amnesia), and demographically matched healthy participants, in their on-line interpretation of ambiguous sentences and the ability to update their verb bias with experience. We find that (1) patients and their healthy counterparts use existing verb bias to successfully interpret on-line ambiguity, however (2) unlike healthy young adults, neither group updated these biases in response to recent exposure. These findings demonstrate that using existing representations of verb bias does not necessitate involvement of the declarative memory system, but leave open the question of whether the ability to update representations of verb-specific biases requires hippocampal engagement.

The Necessity of the Hippocampus for Statistical Learning

Converging evidence points to a role for the hippocampus in statistical learning, but open questions about its necessity remain. Evidence for necessity comes from Schapiro and colleagues who report that a single patient with damage to hippocampus and broader medial temporal lobe cortex was unable to discriminate new from old sequences in several statistical learning tasks. The aim of the current study was to replicate these methods in a larger group of patients who have either damage localized to hippocampus or broader medial temporal lobe damage, to ascertain the necessity of the hippocampus in statistical learning. Patients with hippocampal damage consistently showed less learning overall compared with healthy comparison participants, consistent with an emerging consensus for hippocampal contributions to statistical learning. Interestingly, lesion size did not reliably predict performance. However, patients with hippocampal damage were not uniformly at chance and demonstrated above-chance performance in some task variants. These results suggest that hippocampus is necessary for statistical learning levels achieved by most healthy comparison participants but significant hippocampal pathology alone does not abolish such learning.

Expanding the Language Network: Direct Contributions from the Hippocampus

New research suggests that the same hippocampal computations used in support of memory are also used for language processing, providing direct neurophysiological evidence of a shared neural mechanism for memory and language. This work expands classic memory and language models and represents a new opportunity for studying the memory-language interface.