June 25, 2002 Feature

Traumatic Brain Injury

A Primer for Professionals

First, the eye-opening demographics: In the United States, nearly 1.5 million individuals suffer traumatic brain injury (TBI) each year, 13,000 children receive services for TBI in the public schools, and it is estimated that nearly 5.3 million people live with TBI-related disabilities. Adolescents and young adults age 15–24 have the highest incidence of TBI, typically associated with motor vehicle accidents. Older adults over the age of 65 and children under the age of 5 have the next highest incidence of TBI, most commonly resulting from falls. Males are nearly twice as likely to experience a TBI than females, and individuals with TBI are three times more likely to incur a subsequent TBI.

The financial consequences of TBI are staggering. It is estimated that over $48 billion is spent in the United States alone on acute medical and rehabilitation services each year for the treatment of TBI. For acute care, the average length of stay is 22 days, and the average cost is $98,000 per patient. For inpatient rehabilitation, the average length of stay is 32 days, and the average cost is $43,000 per patient.

Definitions

TBI may be thought of as a subset

Definition of Mild Traumatic Brain Injury

Trauma-induced physiological disruption of brain function as evidenced by at least one of the following:

  • a period of loss of consciousness not greater than 30 minutes
  • GCS score of at least 13 by 30 minutes following injury
  • loss of memory for events before or after injury (PTA less than 24 hours)
  • any alteration in mental state
  • focal neurological deficits that may or may not be transient
  • if standard radiological studies (e.g., CT scan or MRI) are done, they must be interpreted as normal

From the Mild Traumatic Brain Injury Committee of the American Congress of Rehabilitation

of acquired brain injury (ABI) and, although some individuals advocate for the use of the more generic term ABI, for the purposes of this article, the more specific term TBI will be used.

TBI results from a variety of etiologic factors including motor vehicle accidents, falls, gunshot wounds, or other trauma involving a blow to the head. The extent of brain trauma following TBI is determined by a combination of primary damage ranging from large to microscopic brain lesions caused by impact to the head, and secondary damage resulting from such factors as infection, oxygen deprivation, brain swelling, and elevated intracranial pressure.

TBI is classified into two broad categories: open (penetrating) and closed (non-penetrating), depending on whether or not the meninges remain intact. Open head injuries result when the scalp, skull, and meninges are penetrated, as in a gunshot wound. Primary damage associated with closed head injuries are the result of mechanical forces involving direct contact and inertia. The point of impact is referred to as "coup," whereas the damage to a brain site opposite that of the point of impact is "contrecoup."

Forces of impact cause the brain to bounce around the rough, somewhat jagged inner surfaces of the skull, resulting in contusions and bruising. The inertial forces involved in closed head injuries are similar to whiplash injuries in which there is rapid acceleration and deceleration. Such rapid twisting movements strain delicate blood vessels and nerve fibers and lead to stretching, shearing, and tearing of these structures. This type of injury is referred to as diffuse axonal injury.

There are a variety of indices of TBI severity. Some of the more commonly applied measures are the Glascow Coma Scale (GCS), duration of coma, and length of post-traumatic amnesia (see "Severity" sidebar on page 6). The GCS assesses severity of injury by rating the degree of eye opening, the best verbal response, and the best motor response. Coma is a prolonged period of unconsciousness, and in most instances a longer duration of coma is associated with greater severity at injury. Post-traumatic amnesia (PTA) refers to the length of time during which memories aren't stored and thus new learning cannot occur.

No two injuries are the same; consequently, TBI results in a diverse, idiosyncratic constellation of cognitive-communicative, physical, and psychosocial deficits. The most common sequela of TBI is a reduced capacity to pursue premorbid interests and daily activities at the same functional level. Such difficulties exist along a broad continuum that can range from needing additional time to complete tasks to near total dependence on others for all basic needs. It has been estimated that approximately 75% of all cases of TBI can be characterized as mild (see sidebar above for definition).

The most characteristic features of TBI are the resulting cognitive disturbances that are often present after the injury. Multiple areas may be disrupted, including attention, memory, organization, reasoning, executive functioning, communication, and social skills. Recovery following TBI progresses through a series of predictable stages (see sidebar above). However, it is important to emphasize that recovery is specific to individual circumstances and therefore may vary in both extent and rate. Pre-injury abilities, personality of the individual, and severity of the injury all influence recovery.

Evidence-Based Practice Guidelines

Recently, a national trend of referencing research evidence to support clinical decision making for the management of medical conditions has surfaced. Consistent with this movement, the Academy of Neurologic Communication Disorders and Sciences—in conjunction with ASHA's Special Interest Division 2, Neurophysiology and Neurogenic Speech and Language Disorders—established committees of experts to develop evidence-based practice guidelines (EBPGs). The guidelines cover the management of dysarthria, aphasia, dementia, apraxia of speech, and cognitive-communication disorders following traumatic brain injury.

The committee developing the EBPGs for TBI identified several assumptions about the nature and management of cognitive-communication disorders following TBI (see sidebar on page 7). In addition, the committee delineated five modules for organizing the research evidence, including remediation of attention, memory, social skills, and metacognition/executive function, as well as assessment tools and procedures. Technical reports on EBPGs for each module will be compiled. To date the EBPG-TBI committee has submitted two reports that will be published in the Journal of Medical Speech-Language Pathology. A few reports from other EBPG committees have already appeared in that journal.

Family Involvement

Family involvement is important in all stages of recovery and rehabilitation. In the early stages of care, the family should be encouraged to participate in the development of the treatment plan with the rehabilitation team. The family may be instructed to assist with specific treatment activities and to promote carryover. Family education is an ongoing process with the primary goal of developing the skills necessary to assist the individual with TBI at home and in the community.

The rehabilitation team also assists the family in planning for the future and becoming an advocate for the individua l with TBI. Caring for a person with a TBI can be an overwhelming responsibility. Many families and caregivers are unaware of the medical, financial, or social implications of brain injury and are uncertain how or where to find information. Although there are many sources that can be consulted, the Internet is often a good place to start. Many Web sites offer links to specific information regarding regional and local resources that may provide answers to questions families may not think to ask.

Culturally and Linguistically Diverse Populations

TBI occurs in all culturally and linguistically diverse populations. Cultural competence is integral to serving these populations. Cultural competence is the consonant set of behaviors, attitudes, and policies within an individual or organization that allows that person or group to interact effectively with individuals from different cultural backgrounds.

The ability to function adeptly and actively in cross-cultural contexts is critical to delivering meaningful services to culturally and linguistically diverse populations. Clinicians must evaluate the individual's cultural and linguistic context, selecting and implementing TBI assessments and intervention programs that are culturally relevant and meaningful. It is equally important for clinicians to understand how the cultural and linguistic background of individuals with TBI influences their feelings about health and health care.

Clinicians also need to examine their own biases and value system and be aware of how their beliefs influence interactions with individuals with TBI. By identifying and addressing the cultural and linguistic factors that may hinder or foster intervention, clinicians can increase the chances for the success of services (see sidebar above). Through cultural competence, clinicians can provide better care for individuals with TBI from unique cultural backgrounds, laying the foundations for better outcomes.

School Re-Entry

Many children with TBI return to school and often experience difficulty learning new information, understanding abstract material, learning in the presence of distractions, and organizing information. In addition, their impaired social and pragmatic skills affect relationships with peers, teachers, and family members. Transitional planning must carefully address these issues to promote the student's academic success, which will determine future social and vocational competency.

Successful re-entry to school involves collaboration among the student, the parents, and staff from the school and medical facility in developing and conducting assessment and intervention procedures. Ongoing, authentic assessments of students with TBI are critical to providing effective intervention.

The nature of the SLP's intervention in the educational setting depends on the learning needs of the student. For students with less severe injuries, the clinician may provide services through consultation and offering instructional strategies to family members, classroom teachers, and support staff. A pullout or classroom-based program may be appropriate for students with more intensive cognitive-communicative needs. Along with the remediation of other cognitive abilities, effective intervention must address communication and social skills, necessitating the participation of family, peers, and teachers in functional situations.

Community Reintegration

Returning to the community following a TBI can be challenging. The literature emphasizes that persistent cognitive impairments frequently impede successful community reintegration. Even those individuals who make significant gains in rehabilitation may experience difficulty when returning to premorbid activities. Community reintegration should emphasize a multidisciplinary approach, which also includes peers and family, in the attempt to close the gap between treatment activities and functional competence in the individual's natural environment. The primary focus of community reintegration should be on what the individual with TBI needs to achieve for returning to work, school, and avocational interests (see sidebar above). Ongoing assessment of progress and modification of goals is critical to the success of any community reintegration program.

Kathleen M. Youse, is a doctoral student in the communication sciences department at the University of Connecticut and an SLP at Hartford Hospital, in Hartford, CT. Contact her by email at kathleen.youse@uconn.edu.

Karen N. Le, is a graduate student and research assistant in the communication sciences department at the University of Connecticut. Contact her by email at karen.le@uconn.edu.

Michael S. Cannizzaro, is a doctoral student in the communication sciences department at the University of Connecticut. Contact him by email at michael.cannizzaro@uconn.edu.

Carl A. Coelho, is an associate professor in the communication sciences department at the University of Connecticut and an SLP at the Hospital for Special Care in New Britain, CT. Contact him by email at coelho@uconn.edu.

cite as: Youse, K. M. , Le, K. N. , Cannizzaro, M. S.  & Coelho, C. A. (2002, June 25). Traumatic Brain Injury : A Primer for Professionals. The ASHA Leader.

Strategies for Community Reintegration

Community/Family Environment

  • Assess family’s ability to facilitate cognitive remediation in the home
  • Provide clear demonstrations and multiple opportunities for the individual with TBI and family to practice new skills
  • Increase opportunities for socialization and recreation to reestablish social networks
  • Allow the individual with TBI to systematically assume greater responsibility for planning and completing activities

Work Environment

  • Conduct assessment in the actual place of employment 
  • Evaluate social and physical obstacles
  • Use a job coach to facilitate success on the job
  • Integrate adaptation and compensatory strategies


Working With Culturally and Linguistically Diverse Groups

  • Identify the cultural and linguistic background of the individual with TBI 
  • Learn about the culture, beliefs, and values of the individual with TBI and how these affect attitudes toward injury and management of health
  • Use culturally relevant and meaningful assessment and intervention tools.
  • Seek thoughts and feelings of family members and involve them in clinical decision-making and intervention process
  • Create and distribute culturally appropriate materials to promote awareness of TBI and available resources in the community
  • Use interpreters and translators with appropriate training
  • Conduct ongoing advocacy and outreach on TBI through community/cultural centers
  • Conduct cultural competence assessment


Managing Cognitive-Communication Disorders Following TBI

  1. Management of cognitive-communication disorders is an integral part of SLPs’ scope of practice. SLPs are uniquely trained to manage these disorders with clinical knowledge in the interaction between cognition and communication.
  2. Managing cognitive-communication disorders is an interdisciplinary endeavor.
  3. Cognitive-communication intervention does not include communication intervention for aphasia or motor-speech disorders following TBI.
  4. There are many approaches to cognitive-communication intervention—behavioral approaches, skill training, process-specific approaches, and multi-modal approaches.
  5. Numerous service delivery models exist—in-patient medical rehabilitation, long-term care, outpatient care, job coaching, school-based services, day-treatment, transitional living programs, or individual and group therapy.
  6. Improvements in impairments may or may not facilitate a change in an individual’s activity or participation level and vice versa.
  7. The ultimate goal of cognitive-communication intervention is to achieve the highest level of communicative participation in everyday living.


TBI Prevention

Motor Vehicles

  • Using a seatbelt in combination with an airbag reduces the risk of head injury by 81%, compared to 60% for seatbelts alone
  • Children should ride in age and size appropriate car seats; learn to use car seats properly (www.safekids.org)
  • Children under the age of 12 years should never ride in the front seat of a car equipped with an airbag
  • Never drink and drive—41% of individuals with TBI test positive for alcohol at time of injury

Bicycles

  • Always wear a helmet, even on short rides
  • Wearing reflective clothing allows riders to be seen at dusk or at night
  • Bicycles should have a headlight and reflectors
  • Children should ride on sidewalks or paths until they are at least 10 years old or show the ability to follow basic rules of the road

Motorcycles

  • Wearing a motorcycle helmet reduces the risk of a brain injury by 67%
  • Obey speed limits—40% of motorcyclists who die in crashes are speeding
  • Turn headlight on every time you ride
  • Don’t carry passengers until you are skilled at driving in all kinds of conditions
  • Take a motorcycle safety course—call 800-446-9227

Playground Safety

  • Supervise children at all times
  • Children should always play on equipment that is age appropriate
  • Choose playgrounds with soft under-surfaces that will cushion a fall
  • Make sure there is fencing between the playground and the street
  • Check playground equipment to be certain it is in good repair

Preventing Falls Among Older Adults 

  • Begin an exercise program to increase strength and balance 
  • Use non-slip mats in the bathtub and on shower floors 
  • Remove things that can be easily tripped over 
  • Improve lighting in the home 
  • Wear shoes with good support and non-slip soles


Stages of Recovery

1. Coma: unresponsive; eyes closed

2. Vegetative state: no cognitive responses; gross wakefulness; sleep-wake cycles

3. Minimally conscious state: purposeful wakefulness; responds to some commands

4. Confusional state: recovered speech; amnesic (PTA); severe attentional deficits; agitated; hypoaroused; possible labile behavior

5. Postconfusional, evolving independence: resolution of PTA; cognitive improvement; achieving independence in daily self-care; improving social interaction; developing independence at home

6. Social competence, community re-entry: recovering cognitive abilities; goal-directed behaviors; social skills; personality; developing independence in the community; returning to academic or vocational pursuits

Reprinted with permission from: Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. NY: Guilford Press.


Severity

Classification GCS Score Duration of Coma Length of PTA
Severe 3–8 Over 6 hours Over 24 hours
Moderate 9–12 Less than 6 hours 1–24 hours
Mild 13–15 20 minutes or less 60 minutes or less

Reprinted with permission from: Sohlberg, M. M, & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. NY: Guilford Press.



Improving Cognitive-Communicative and Social Skills

Cognitive-Communicative

  • Present new material in an organized and sequential manner with clear explanations, using visual aids or other teaching aids
  • Provide repetitions and multiple opportunities for practicing new skills
  • Encourage responsiveness and allow adequate time for the client to respond
  • Use alternative or augmentative communication where appropriate and functional
  • Focus on attention and memory skills
  • Promote the use of higher level thinking (i.e., problem-solving, reasoning)

Social Skills

  • Allow the client to participate in the selection and prioritization of target skills
  • Facilitate acquisition and understanding of client’s social knowledge
  • Create awareness of social settings, social interactions, and corresponding appropriate modes of behavior and communication
  • Educate and train family members how to best interact with client
  • Focus on self-monitoring and self-evaluating behavior and performance
  • Use role-playing and scripting to practice social interactions


  

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