Remediating narrative discourse impairments in veterans with TBI: Initial treatment development

认知-沟通障碍在颅脑损伤后普遍存在，在 语篇(句子以外的有意义的语言)和社会互动。话语障碍的影响 在主要生命领域发挥作用。研究一直表明，有话语障碍的人 在TBI之后，难以获得和维护工作，与社会关系作斗争，体验社会 与世隔绝，并报告生活质量下降。此外，话语障碍影响到所有严重程度的脑损伤 并随着时间的推移而坚持下去。脑外伤后语篇功能障碍的影响及其长期性 治疗这些损伤的重要性。 这份CDA-2申请的首要目标是为求职者在认知领域的职业生涯做好准备。 针对脑外伤患者话语障碍的交际干预研究。建议的目标是 该项目是为患有脑外伤的退伍军人开发和试验一种话语治疗。该项目的培训目标是 为了：1)发展治疗开发方面的专业知识，2)加强脑外伤相关并发症的背景，3) 扩展远程康复和计算机辅助交付的知识，4)发展进行 行为干预的随机临床试验(RCT)，包括统计和方法学 方法，以及5)进一步的科学写作、演示技能和恩赐精神。 叙事是一种根植于日常对话中的基本语篇体裁。GLOBAL的细分 在脑外伤患者中，叙述性话语水平是一个一致的发现，在故事水平上也是显而易见的 内容和故事组织。故事内容的缺陷包括完整性和完整性的缺陷 信息的准确性、全球一致性和摘要。故事组织中的缺陷包括 故事语法元素、事件顺序(情节)和叙事比例的减少 按剧集组织。 跨文化交际中的话语干预是一个新的研究领域，到目前为止，只有少数几个 试图提高任务型教学中的语篇能力的研究。这些以前的尝试都是小案例 研究，没有产生变化或收获有限，不包括患有脑损伤的退伍军人。建议的项目是 一项将评估小说叙事可行性的早期话语处理发展研究 话语治疗方案，建立在所有资深参与者样本的这些先前尝试的基础上。 研究的第一阶段将包括初步手动开发话语处理方案 并通过小样本参与者(5-10名参与者)进行改进。该协议将纳入来自 先前的治疗研究显示出一些希望：1)分层训练，2)各种话语刺激，3) 发展语篇处理的技能和策略，4)结构化训练提示，5)元认知 和元语言策略，以及6)学习原则的整合。新的治疗要素将包括： 1)针对故事内容和故事组织，2)使用话语模式来指导治疗，3) 功能沟通训练。治疗将在8周内每周进行两次，一次面对面 以及每周一次的远程健康会议。将有四个治疗阶段：教育、故事组织、 故事内容，以及故事组织和内容的整合。 第二阶段将在单独的参与者样本上进行治疗可行性试验，以获得 关于拟议的话语处理的耐受性、可接受性和保真度的信息以及 关于提供治疗和评估方法的初步数据以及以下方面的初步信息 治疗效果。40名参与者将被随机分为话语治疗组和AS治疗组 通常的控制。评估将在基线、治疗后和1个月后进行，并将 包括话语能力、认知、心理健康、功能交流和日常功能的测量。

Cognitive-communication disorders are pervasive following TBI, disrupting communication at the level of discourse (meaningful language beyond sentence level) and social interaction. Discourse impairments impact functioning across major life domains. Research consistently shows that people with discourse impairments following TBI have difficulty securing and maintaining work, struggle with social relationships, experience social isolation, and report a decline in quality of life. Moreover, discourse impairments affect all severity levels of TBI and persist over time. The functional impact and chronicity of discourse impairments following TBI underscore the importance of treating these impairments. The overarching goal of this CDA-2 application is to prepare the candidate for a career in cognitive- communicative interventions research to address discourse impairments in TBI. The aims of the proposed project are to develop and trial a discourse treatment for veterans with TBI. Training goals for the project are to: 1) develop expertise in treatment development, 2) strengthen background in TBI-related comorbidities, 3) expand knowledge of telerehabilitation and computer-aided delivery, 4) develop expertise in conducting randomized clinical trials (RCTs) of behavioral interventions, including statistical and methodological approaches, and 5) further scientific writing, presentation skills, and grantsmanship. Narratives are a fundamental discourse genre embedded in daily conversation. Breakdowns at global levels of narrative discourse are a consistent finding in people with TBI and are apparent at the level of story content and story organization. Impairments in story content include deficiencies in completeness and accuracy of information, global coherence, and summarization. Impairments in story organization include reductions in story grammar elements, sequences of events (episodes) and proportion of the narrative organized by episodes. Discourse intervention in TBI is a nascent area of research, and, to date, there have been only a few studies that have attempted to improve discourse ability in TBI. These prior attempts have been small case studies, produced no change or limited gains, and did not include veterans with TBI. The proposed project is an early stage discourse treatment development study that will evaluate the feasibility of a novel narrative discourse treatment protocol that builds upon these prior attempts with an all-veteran participant sample. The first phase of the study will consist of initial manual development for the discourse treatment protocol and refinement with a small participant sample (5-10 participants). The protocol will incorporate elements from prior treatment studies that showed some promise: 1) hierarchical training, 2) variety of discourse stimuli, 3) development of skills and strategies for discourse processing, 4) structured training prompts, 5) meta-cognitive and meta-linguistic strategies, and 6) integration of learning principles. Novel treatment elements will include: 1) targeting both story content and story organization, 2) use of a discourse model to guide treatment, and 3) functional communication training. Treatment will be delivered twice a week over 8 weeks, with one in-person and one telehealth session each week. There will be four treatment phases: education, story organization, story content, and integration of story organization and content. The second phase will be a treatment feasibility trial on a separate sample of participants to obtain information regarding the tolerability, acceptability, and fidelity of the proposed discourse treatment and preliminary data on treatment delivery and assessment methods as well as preliminary information about treatment effects. Forty participants will be randomized to either the discourse treatment group or Treatment as Usual control. Assessments will be conducted at baseline, post-treatment, and at 1-month follow-up, and will include measures of discourse ability, cognition, mental health, functional communication and daily functioning.