Statement - A Speech-Language Pathologist's Perspective on Mild Traumatic Brain Injury (MTBI)

Kathy Manning, MS, CCC-SLP
Neuro Rehab Associates - Bozeman, Montana

At least 1.4 million traumatic brain injuries are reported in the United States annually, the vast majority of which are considered "mild" by medical definition. Conservatively, 15-20% of those individuals will suffer long-term disabilities. Despite these numbers, MTBI remains poorly understood by the general public, and at times, even by medical professionals. Diagnosis of MTBI can be challenging, and is often missed or delayed, resulting in inadequate treatment.

There is nothing mild about MTBI, at least for those who endure the long-term consequences. These individuals may suffer a wide range of physical, emotional, social, behavioral, cognitive, and language problems. Some of the most common physical problems include severe headache, fatigue, sleep disorder, chronic pain, balance and visual disorders, and light/noise sensitivity. Emotional and behavioral issues can include depression, anxiety, fear, social isolation, apathy, and withdrawal. In the cognitive-linguistic domains, deficits most commonly occur in attention, memory, executive function skills, speed of information processing, pragmatic language and discourse, reasoning, and problem solving.

These issues are further complicated by the "hidden" quality of this disability; none of these symptoms are necessarily obvious to the casual observer, and it is often difficult to medically prove the presence of MTBI due to the limitations in existing technology. Those with MTBI appear outwardly normal and as a result, may not receive adequate support from employers, family members and friends. Insurance companies frequently deny or restrict outpatient treatment, particularly for cognitive rehabilitation or deny the presence of a brain injury altogether. Financial issues can become devastating if the individual is unable to continue working due to the severity of their symptoms. Contentious litigation may ensue if the injury was a result of an accident, further contributing to emotional stress and financial burdens. If medical professionals fail to recognize the severity or extent of problems and treatment is delayed, many symptoms may become exacerbated. Additionally, those who lack an understanding of brain injury may treat individuals with MTBI as malingerers or attention seekers.

When adequate and timely intervention is provided, however, the prognosis and outcome can be very good. For the speech-language pathologist, treatment of MTBI requires specific knowledge and skills, and the focus of treatment is often quite different from that provided to the individual with a more moderate or severe brain injury. Therapeutic intervention must include comprehensive evaluation, extensive and ongoing client education, access to resources and referrals, and family education. Skill building activities must support the development of independent use of compensatory strategies that can be generalized to functional skills. Development of metacognitive skills is essential to that carryover and the client's ability to predict and apply those compensatory strategies independently. The cognitive domains of attention, memory, information processing, executive function and language are interactive functions and must be viewed in that context rather than treated as separate entities. Additionally, the therapist must be sensitive to the daily challenges of the client, and adjust therapy accordingly. Throughout the therapeutic process, supportive counseling is also essential, and includes developing and encouraging advocacy. The complexity of these issues requires fairly long term intervention for many clients.

There is still much to be accomplished in the treatment of MTBI. Greater public awareness and understanding is essential, as is continued research to develop diagnostic tools that better assess the nature and extent of deficits, and identify the benefits of appropriate intervention. Education of medical professionals and ancillary support services is needed, so that injuries do not go undiagnosed, and early referrals can be made. Changes in attitude toward MTBI in the insurance industry would provide better access to health care and promote faster recovery. Prevention, where possible, is critical, particularly in the case of sports injuries, falls among the elderly, and motor vehicle accidents related to alcohol.

In Montana, members of the state Brain Injury Association have moved away from using the terminology of "brain injury survivor" in favor of "brain injury thriver". This is a critical point. It is not enough to survive a traumatic brain injury; those who have been injured desire a quality of life that is worth having. To that end, we owe these courageous individuals support, respect, and access to appropriate and adequate treatment.