See the Screening section of the Traumatic Brain Injury (Adults) Evidence Map for relevant evidence, expert opinion, and client/patient perspective.
Screening is conducted by the speech-language pathologist, audiologist, or other professionals on the interdisciplinary care team, to identify possible areas of deficits following a traumatic brain injury (TBI). Screening is typically completed prior to conducting more comprehensive evaluations. Screening does not provide a detailed description of the severity and characteristics of deficits resulting from TBI, but rather identifies the need for further assessment. Screening may result in recommendations for rescreening, for comprehensive assessments, or for referral for other examinations or services.
Speech, Language, Cognitive-Communication, and Swallowing Screening
SLPs screen for speech, language, cognitive-communication, and swallowing deficits using appropriate standardized instruments or nonstandardized procedures. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic variables. Results of screening procedures are interpreted within the context of the individual's sensory deficits.
Hearing screening and otoscopic inspection for impacted cerumen occur prior to screening for other deficits. If the individual wears hearing aids, the hearing aids should be inspected by an audiologist to ensure that they are in working order and be worn by the individual during screening. Hearing screening is within the scope of practice for SLPs.
If the individual fails the hearing screening or if hearing loss is suspected, a referral for a full audiologic evaluation is necessary. In addition to hearing screening, audiologists may also screen for vestibular deficits as indicated. See assessment: hearing loss, ages 5+.
Although SLPs and audiologists do not diagnose TBI, they need a clear understanding of the individual's medical assessment, physical condition, course of recovery, and the nature/effects of the neurological damage, to guide development of an appropriate assessment plan (Hegde, 2006). The assessment of an individual with TBI requires a multidisciplinary approach involving medical, surgical, and rehabilitation disciplines as necessitated by the individual's needs.
See the Assessment section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Comprehensive SLP Assessment
Individuals suspected of having communication-cognitive or swallowing deficits are referred for a more comprehensive assessment to the SLP. Assessments can be completed within the clinical setting or in the individual's current living environment. Assessment is completed in the language(s) used by the person with TBI with the use of translation/interpretation services as necessary. See collaborating with interpreters.
Assessment of individuals with TBI is conducted to identify and describe
- underlying strengths and weaknesses in linguistic processing (spoken and written language in different response modalities) and speech production (including articulation, voice, and fluency) that affect communication performance and participation in activities of daily living;
- underlying strengths and weaknesses related to cognitive processing, including social skills, that impact communication performance and potential return to prior level of function in activities of daily living;
- the presence of dysphagia and which phase(s) of swallowing may be impaired, appropriate means of nutritional intake, including safe diet consistency for oral intake, and appropriate compensatory strategies that maximize swallow safety;
- contextual factors that serve as barriers to or facilitators of successful communication and life participation;
- the impact of speech, language, cognitive-communication, and swallowing impairments on quality of life and functional/participation limitations relative to premorbid social roles and abilities for the individual and the impact on his/her community.
Assessment typically includes the following.
- Relevant case history, including medical status, education, occupation, and socioeconomic, cultural, and linguistic backgrounds.
- Due to the complexity of cognitive sequelae in TBI and its influence on bilingual language production (Penn, Frankel, Watermeyer, & Russell, 2010), a thorough case history and interviews with the family and individual are particularly beneficial in identifying premorbid language proficiency, language preference for assessment/treatment of linguistic deficits, and communicative needs in the community (Lorenzen & Murray, 2008).
- Review of auditory, visual, motor, cognitive, and emotional status.
- Individuals with suspected visual deficits are referred for comprehensive vision testing by a qualified professional prior to any assessment. Appropriate assistive visual aids (e.g., prescriptive glasses) and environmental modifications (e.g., large-print material, modified lighting, etc.) are used as needed.
- Individuals suspected of hearing or balance impairments are referred for a comprehensive audiologic assessment prior to any other testing. See assessment: hearing loss, ages 5+
- Evaluation of the integrity of the speech subsystems (e.g., respiration, phonation), oral-motor mechanisms, and speech motor planning and their impact on communication and swallowing.
- Standardized and nonstandardized methods, selected with consideration of ecological validity (including analysis of natural communication samples gathered in different modalities (listening, speaking, reading, or writing) and contexts (social, educational, or vocational).
- Appropriate accommodations and modifications can be made to the testing process to reconcile cultural and linguistic variations. Comprehensive documentation includes descriptions of these accommodations and modifications. Scores from standardized tests should be interpreted and reported with caution in these cases.
- The SLP considers the influence of cultural and linguistic factors on the individual's communication style and the potential impact of impairment on function when selecting screening and assessment tests.
- The individual's reported areas of concern (memory, speaking, swallowing), contexts of concern (e.g., social interactions, work activities), and language(s) used in those contexts, as well as the individual's goals and preferences.
- Identification of contextual barriers and facilitators and the potential for effective compensatory techniques and strategies, including the use of cognitive aids and augmentative and alternative communication (AAC). See ASHA's Practice Portal Page on Augmentative and Alternative Communication.
- Identification of relevant follow-up services for appropriate intervention and support for individuals with TBI.
Assessment typically results in
- diagnosis of a speech, language, voice, cognitive-communication, and/or swallowing disorder;
- clinical description of the characteristics and severity of the disorder(s);
- prognosis for change (in the individual or relevant contexts);
- recommendations for intervention and support;
- identification of the effectiveness of intervention and supports;
- referral for other assessments or services.
General Assessment Considerations
A comprehensive assessment addresses the components within the WHO International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2007; WHO, 2001), including body structures/functions, activities/participation, and personal/environmental factors, and is sensitive to cultural and linguistic diversity. Assessment considerations specific to TBI include the following.
- Interdisciplinary collaboration is necessary to ensure that the individual with TBI is not over-tested or exposed to practice effects consequent to repeated exposure to stimuli and to maximize the breadth and depth of skills assessed.
- Depression (which can be a consequence of neurological damage or a part of the post-traumatic stress disorder complex) can adversely affect test performance. If signs and symptoms of depression are present or suspected, the individual is referred to a neuropsychologist, clinical psychologist, or psychiatrist for further follow-up.
- The side effects of prescription drugs may impact the individual's presentation and test performance (e.g., excessive drowsiness). Polypharmacy, or the concurrent use of several medications, is common among individuals who have multiple medical conditions, and some medications may exacerbate cognitive problems.
- The effects of repeated TBI, as indicated in the individual's case history and/or in the medical record, are considered while determining the individual's prior level of function and baseline skill levels. Repeated TBI may result in chronic traumatic encephalopathy (CTE), influencing the individual's overall cognitive and behavioral function and increasing the risk for dementia (Stern et al., 2011).
Periodic, ongoing assessment of individuals with TBI is important, because neurological recovery can occur for several months or longer after some types of severe brain injury. Ongoing assessment can also be used to examine an individuals' responses to rehabilitation and to life after the injury.
Assessment methods may include standardized and nonstandardized procedures. The decision to use standardized or nonstandardized assessment procedures is based upon a variety of factors, including the needs of the person with TBI, the complexity of impairment, payer rules, and facility policy.
Standardized testing with a battery of assessments helps identify areas of weakness to be addressed in treatment and/or areas of strength that can be used to compensate for ongoing weaknesses. When appropriate, an entire standardized test battery is administered. In other cases, the clinician may give selected subtests from standardized test batteries, recognizing the impact on the psychometric properties when using subtests in this manner. When tools are not administered according to standardized procedures, standard scores must be interpreted and reported with caution.
There is currently a paucity of standardized communication assessments for use with patients suffering from TBI. When selecting a standardized assessment tool, clinicians consider the severity level of the individual's underlying neurological damage and the individual's level of alertness, as well as comorbid physical, sensory, and cognitive deficits. Tests that are too difficult for medically complex individuals will not yield useful information. In addition to selecting tests that assess the targeted areas of deficit, clinicians must also evaluate if the tests selected have been normed for use with TBI.
Nonstandardized procedures are used to systematically probe aspects of speech, language, and cognition. Functional nonstandardized assessment is particularly valuable in individuals with TBI, who often perform disproportionately better or worse in activities of daily living compared with abilities predicted by standardized test scores. Nonstandardized assessment procedures serve a variety of purposes, including identifying
- abilities in domains for which there are no/limited standardized tests,
- available support systems and appropriate education to be provided to communication partners,
- the individual's demands and abilities within functional contexts and activities of daily living,
- strategies and task modifications to maximize the individual's functional abilities,
- tracking outcomes in response to intervention,
- variables that may positively influence task performance and learning within the current living/working environment.
(Coelho, Ylvisaker, & Turkstra, 2005)
Performance scales, patient and family questionnaires, and inventories of skills and weaknesses may also be used to identify the functional needs of each individual and the course of treatment.
The following factors may influence the assessment of cognitive-communication abilities in individuals with TBI:
- level of consciousness and arousal;
- neurobehavioral deficits, such as agitation and combativeness;
- motor deficits (e.g., postural limitations. hemiparesis, limb apraxia) that impact physical endurance and participation;
- sensory deficits (e.g., visual neglect, hearing loss).
Factors impacting the assessment of neurogenic dysphagia following TBI include
- extent/severity of polytrauma;
- impairments in positioning and motor control that may impact self-feeding;
- physical damage to the oral, pharyngeal, and/or laryngeal structures;
- presence of neuromotor movement disorders;
- related neurobehavioral impairments (e.g., perseveration, poor initiation, impulsivity, impaired sequencing, impaired awareness of deficits);
- respiratory status, including presence of tracheostomy and/or use of mechanical ventilation.
(Murdoch & Theodoros, 2001)
The patient's level of arousal, cognitive status, and ability to follow commands are considered throughout ongoing assessment. Depending on the individual's overall alertness and ability to participate, the clinical bedside examination may also include feeding trials of a variety of food textures and liquid consistencies.
While traditional behavioral hearing tests (e.g., pure tone and speech audiometry) are generally appropriate in the audiologic assessment of individuals with TBI, modifications to testing procedures may be necessary. Modifications include
- simplifying directions,
- using pulsed tones,
- slowing presentation of speech stimuli,
- providing reminders to respond,
- responding with "yes," instead of raising a finger or pressing a button.
Audiologic test results can be confounded by comorbidities, including memory, attention deficits, tinnitus, dizziness, and anxiety, making it difficult to attribute auditory complaints to auditory-only processing deficits.
If the audiologist is unable to obtain accurate test results, more objective tests (e.g., Otoacoustic Emissions or Auditory Brainstem Response testing) may be necessary to obtain estimated the degree of hearing loss present (e.g. normal/mild hearing loss from a more significant hearing loss). Even if valid hearing thresholds are obtained within the normal range, a referral for a test battery that includes speech in noise, temporal processing, and binaural processing may be warranted to assess auditory processing deficits. See the assessment: hearing loss, ages 5+.
Because balance is a multisensory function, during vestibular assessment "clinicians working with individuals with blast trauma need to consider several causes of postural instability, including TBI, orthostatic hypotension, cervical vertigo, visual deficits, possible side effects of ototoxic drugs, and vestibular pathology" (Fausti, Wilmington, Gallun, Myers, & Henry, 2009, p. 804). Vestibular deficits in individuals with TBI can be evaluated using procedures such as
- Dix-Hallpike and roll tests;
- horizontal semicircular canal function tests, including caloric and rotational testing;
- semicircular canal function tests, such as caloric, rotational, and video head impulse testing;
- otolith testing, such as vestibular-evoked myogenic potential (VEMP), and the subjective visual vertical test (SVV);
- videonystamography (VNG).
(Fausti et al., 2009; Wintrow, 2013)
The presence or absence of spontaneous nystagmus and/or positional nystagmus can also serve as an indicator of vestibular adaptation.