Traumatic Brain Injury (TBI)
What is traumatic brain injury (TBI)?
Traumatic brain injury (TBI) is a form of brain injury caused by sudden damage to the brain. Depending on the source of the trauma, TBIs can be either open or closed head injuries.
- Open Head Injuries: Also called penetrating Injuries, these injuries occur when an object (e.g., a bullet) enters the brain and causes damage to specific brain parts. Symptoms vary depending on the part of the brain that is damaged.
- Closed Head Injuries: These injuries result from a blow to the head (e.g., when the head strikes the windshield or dashboard in a car accident).
Irrespective of the cause of the trauma, TBIs result in two types of damage to the brain: primary brain damage, which is damage that occurs at the time of impact (e.g., skull fracture, bleeding, blood clots), and secondary brain damage, which is damage that evolves over time after the trauma (e.g., increased blood pressure within the skull, seizures, brain swelling).
What causes TBI?
The Centers for Disease Control and Prevention has identified the leading causes of TBI to be
- motor vehicle and pedestrian-related accidents,
- collision-related (being struck by or against) events,
- violent assaults.
Sport-related injuries and explosive blasts/military combat injuries are other leading causes of TBI. Acquiring a brain injury may predispose an individual to additional brain injuries before the symptoms of the first one have resolved completely.
How common is TBI?
The Centers for Disease Control and Prevention reports that every year at least 1.7 million TBIs occur in the United States (across all age groups), and TBIs are a contributing factor in about a third (30.5%) of all injury-related deaths. Older adolescents ages 15 to 19 years, adults ages 65 years and older, and males across all age groups are most likely to sustain a TBI (Faul et al., 2010).
How is TBI diagnosed?
TBI is diagnosed by physicians based on a combination of patient reports, clinical presentation, and brain imaging studies (such as CT scans and MRIs). A form of TBI called mild traumatic brain injury (mTBI) is typically diagnosed only on the basis of the individual's (or caregiver's) report and clinical signs and symptoms. Brain imaging findings are typically normal in mTBI.
Though the medical diagnosis of TBI is made by the physician, the specific deficits resulting from TBI are diagnosed and managed by an interdisciplinary team. Depending on the needs of the individual, the team often includes audiologists, doctors, nurses, neuropsychologists, occupational therapists, physical therapists, social workers, employers, and teachers.
What deficits result from TBI?
The consequences of TBI may include physical, sensory, cognitive-communication, swallowing and behavioral issues. These problems significantly impair the affected person's ability to live independently. The problems vary depending on how widespread the brain damage is and the location of the injury.
- Physical problems may include loss of consciousness, seizures, headaches, dizziness, nausea/vomiting, reduced muscle strength (paresis/paralysis), and impairments in movement, balance, and/or coordination, including dyspraxia/apraxia.
- Sensory deficits can involve all sensory modalities depending on the areas of the brain that are involved. A stroke can result in the individual's being either less or more sensitive to sensations, experiencing altered sensations, or being unable to synthesize sensations to identify his or her own location in space.
- Behavioral changes include changes in experiencing or expressing emotions, agitation and/or combativeness, anxiety or stress disorder, and depression. Individual with TBI can also experience mood swings, impulsivity, irritability, and reduced frustration tolerance.
- Cognitive deficits (impairments in thinking skills) may involve changes in awareness of one's surroundings, attention to tasks, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-monitoring, and evaluation). Although new learning is impacted by memory deficits, long-term memory for events and things that occurred before the injury, however, is generally unaffected (e.g., the person will remember names of friends and family). The person may have trouble starting tasks and setting goals to complete them. Planning and organizing a task is an effort, and it is difficult to self-evaluate work. The individual often seems disorganized and needs the assistance of family and friends. He or she also may have difficulty solving problems and may react impulsively (without thinking first) to situations.
- Communication deficits are often characterized by difficulty in understanding or producing speech correctly (aphasia), slurred speech consequent to weak muscles (dysarthria), and/or difficulty in programming oral muscles for speech production (apraxia). It may be an effort for individuals with TBI to understand both written and spoken messages; they may behave as if they are trying to comprehend a foreign language. They may also have difficulty with spelling, writing, and reading. Some individuals may also have difficulty in social communication, such as difficulty taking turns in conversation and problems maintaining a topic of conversation. Most frustrating to families and friends, individuals with TBI may have little or no awareness of just how inappropriate their behaviors are.
- Swallowing deficits (dysphagia) may also result from a stroke due to weakness and/or incoordination of muscles in the mouth and throat.
What does a speech-language pathologist do when working with people with TBI?
The SLP completes a formal evaluation of cognitive-communication and swallowing abilities using a variety of formal and informal measures. An oral examination may also be completed to check the strength and coordination of the muscles that control speech. Understanding and use of grammar (syntax) and vocabulary (semantics), as well as reading and writing, are evaluated.
Social communication skills (pragmatic language) may be evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to interpret/explain jokes, sarcastic comments, or absurdities in stories/pictures (e.g., "What is strange about a person using an umbrella on a sunny day?").
The SLP will assess cognitive-communication skills, including attention and orientation. Recent memory skills are assessed, such as whether the main details in a short story are retained. The SLP assesses the patient's ability to plan, organize, and attend to details (e.g., completing all of the steps for brushing teeth). The person may be asked to provide solutions to problems (reasoning and problem solving; e.g., "What would you do if you locked your keys in your car? How can this problem be avoided in the future?"). For more information about when to refer someone for a cognitive-communication evaluation, see Cognitive-Communication Referral Guidelines for Adults.
If problems are observed, the SLP will evaluate swallowing and make recommendations regarding management and treatment. The focus of this evaluation will be to ensure that the individual is able to swallow safely and receive adequate nutrition. Additional swallowing tests may be recommended as a result of this evaluation.
A treatment plan is developed after the evaluation. The treatment program will vary depending on the stage of recovery, but it will always focus on increasing independence in everyday life.
In the early stages of recovery (e.g., during coma), treatment focuses on:
- getting general responses to sensory stimulation,
- teaching family members how to interact with the loved one.
As an individual becomes more aware, treatment focuses on:
- maintaining attention for basic activities,
- reducing confusion,
- orienting the person to the date, where he or she is, and what has happened.
Later on in recovery, treatment focuses on:
- finding ways to improve memory (e.g., using a memory log);
- learning strategies to help problem solving, reasoning, and organizational skills;
- working on social skills in small groups;
- improving self-monitoring in the hospital, home, and community.
Eventually, treatment may include:
- going on community outings to help the person plan, organize, and carry out trips using memory logs, organizers, checklists, and other helpful aids;
- working with a vocational rehabilitation specialist to help the person get back to work or school.
If the person is learning how to use an augmentative or alternative communication device, treatment will focus on increasing efficiency and effectiveness with the device.
How effective are speech-language treatments for TBI?
ASHA has written a series of treatment efficacy summaries [PDF] that describe evidence about how well treatment following TBI works. These summaries are useful not only to individuals with TBI and caregivers but also to insurance companies considering payment for much-needed services for TBI. The Academy of Neurological Communication Disorders and Sciences has also published a number of treatment efficacy papers.
What other organizations have information about TBI?
This list is not exhaustive, and inclusion does not imply endorsement of the organization or the content of the website by ASHA.