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.