See the Assessment section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
SLPs and audiologists do not diagnose TBI. However, they need to understand the individual's medical assessment, physical condition, course of recovery, and nature of the neurological damage to guide development of an appropriate assessment plan (Hegde, 2018).
Assessment of individuals with TBI requires collaboration with the individual and their family members, medical professionals, rehabilitation specialists, and other professionals. Findings from the speech-language and audiology assessments are considered in the context of findings from other professionals on the team. See ASHA's web page on interprofessional education/interprofessional practice (IPE/IPP) and ASHA's resources on person- and family-centered care, and collaboration and teaming.
Assessments are conducted in the language(s) used by the person with TBI, with the use of translation/interpretation services as necessary. Assessments are sensitive to cultural and linguistic variables. See ASHA's Practice Portal pages on Bilingual Service Delivery and Cultural Competence, and Collaborating With Interpreters, Transliterators, and Translators.
See the Screening section of the Traumatic Brain Injury (Adults) Evidence Map for relevant evidence, expert opinion, and client/patient perspective.
Audiologists and SLPs conduct screening to identify possible deficits following a 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.
Hearing screening and otoscopic inspection for impacted cerumen occur prior to screening for other deficits. If the individual wears hearing aids, an audiologist should inspect the hearing aids to ensure that they are in working order, and the individual should wear the hearing aids during screening. Hearing screening is within the scope of practice for SLPs. See ASHA's Practice Portal page on Adult Hearing Screenings.
Referral for a full audiologic evaluation is necessary if the individual fails the hearing screening or if hearing loss is suspected. Audiologists may also screen for tinnitus and vestibular deficits as indicated. See ASHA's Practice Portal pages on Hearing Loss—Beyond Early Childhood, Tinnitus and Hyperacusis, and Balance System Disorders.
Speech, Language, Cognitive-Communication, and Swallowing Screening
SLPs screen for speech, language, cognitive-communication, and swallowing deficits using appropriate standardized instruments or nonstandardized procedures. A referral is made for comprehensive assessment in one or more of these areas if the individual fails that portion of the screening.
The purpose of a comprehensive assessment for individuals with TBI is to determine speech, language, cognitive-communication, swallowing, and audiologic strengths and needs.
If an individual wears prescription eyeglasses or hearing aids, and prescriptions are still appropriate post injury, then he or she should wear the glasses or aids during assessment.
If the TBI resulted in additional hearing or visual deficits, then sensory aids and/or accommodations used before the injury may not be sufficient. Physical or environmental modifications may be needed (e.g., large-print material, modified lighting, amplification devices).
If changes to premorbid hearing and/or vision are significant, then the individual is referred for comprehensive audiologic and/or vision assessments prior to any additional testing. See the Assessment section of ASHA's Practice Portal page on Hearing Loss—Beyond Early Childhood.
Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), ongoing comprehensive assessment of individuals with TBI is conducted to identify and describe the following:
- Impairments in body structure and function, including underlying strengths and weaknesses in areas known to be affected by TBI.
- Limitations in activities and participation, including functional communication, interpersonal interactions, self-care, and resuming their preinjury roles.
- Impact of communication impairments on quality of life, functional limitations relative to premorbid social roles, and the impact on his or her community.
- Contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication and life participation. These can include the following:
- Facilitators—ability and willingness to use compensatory strategies for day-to-day communication and in the classroom; family support; motivation to improve function.
- Barriers—decreased confidence in one's ability to communicate; presence of cognitive deficits; visual and motor impairments; lack of awareness of disability.
See the ASHA resource titled Person-Centered Focus on Function: Traumatic Brain Injury [PDF] for an example of assessment data consistent with ICF.
Assessment protocols can include both standardized and nonstandardized tools and data sources. See ASHA's resource on assessment tools, techniques, and data sources. The decision to use standardized or nonstandardized tools 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 Assessment—Currently, there are few standardized communication assessments for use with individuals TBI. When selecting a standardized assessment tool, clinicians consider
- the severity of the underlying neurological damage;
- the individual's level of alertness;
- the presence of comorbid physical, sensory, and cognitive deficits; and
- cultural and linguistic representation in the norming population.
Tests that are too difficult for individuals with severe deficits 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 Assessment—Functional nonstandardized assessments are particularly valuable because individuals with TBI 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
- the individual's abilities in domains for which there are no, or limited, standardized tests;
- the individual's abilities within functional contexts and activities of daily living;
- strategies and task modifications to maximize the individual's functional abilities in various communication contexts;
- helpful information for communication partners; and
- outcomes in response to intervention (Coelho, Ylvisaker, & Turkstra, 2005).
- Nature and onset of TBI and related hospitalizations
- Medical status—current and prior to injury
- Current medications
- Review of auditory, visual, motor, and cognitive status
- Review of emotional and mental status
- Educational and occupational background
- Reported areas of concern (e.g., memory, speaking, swallowing) and contexts of concern (e.g., social interactions, work activities)
- Language(s) used in contexts of concern
- Impact of current condition on the individual and their family/caregivers
- Goals and priorities of the individual and their family/caregivers
- Integrity of speech subsystems (respiration, phonation, oral articulators)
- Strength, speed, and range of motion of the oral–motor system components
- Sequential/alternating movement repetitions (diadochokinesis)
- Steadiness, tone, and accuracy of movements for speech and nonspeech tasks
- Vocal quality and ability to change loudness and pitch (see ASHA's Practice Portal page on Voice Disorders)
- Stress testing—2 to 4 minutes of reading or speaking aloud to assess deterioration over time to determine if dysarthria is present (see ASHA's Practice Portal page on Dysarthria in Adults)
- Motor speech planning or programming—repetition of simple and complex multisyllabic words and sentences to determine if apraxia of speech (AOS) is present (see ASHA's Practice Portal page on Acquired Apraxia of Speech)
- Speech intelligibility—the degree to which the listener understands the individual's speech
- Speech comprehensibility—the degree to which the listener understands the spoken message, given other contextual information (e.g., topic, context, gestures)
- Aspects of verbal or nonverbal communication that may be affected by disruptions in cognition (e.g., attention, memory, organization, executive function; see ASHA's resources on cognitive-communication)
- Swallowing function with various foods and food textures (see ASHA's Practice Portal page on Adult Dysphagia)
Other Assessment Components
- Identification of contextual barriers and facilitators and the potential for effective compensatory techniques and strategies, including the use of cognitive aids and AAC. See ASHA's Practice Portal Page on Augmentative and Alternative Communication.
- Identification of relevant follow-up services for appropriate intervention and support.
- Review case history information, including medical information and emotional and mental status
- Review previous assessments (e.g., speech-language, physical therapy, occupational therapy, audiologic)
- Gather additional details related to hearing, balance, and auditory processing difficulties
Behavioral Hearing Testing
- Pure-tone and speech audiometry, including modifications (as needed) such as
- Otoacoustic emissions or auditory brainstem response testing—if accurate test results cannot be obtained using traditional behavioral testing methods
See the Assessment section of ASHA's Practice Portal pages on Permanent Childhood Hearing Loss and Hearing Loss—Beyond Early Childhood.
- Speech in noise
- Temporal processing
- Binaural processing
- Dix-Hallpike and roll tests
- Semicircular canal function tests, such as caloric, rotational, and video head impulse testing
- Otolith testing, such as (a) ocular and cervical vestibular-evoked myogenic potential (VEMP) and (b) the subjective visual vertical (SVV) test
- Videonystamography (VNG)
(Fausti, Wilmington, Gallun, Myers, & Henry, 2009; Wintrow, 2013)
See the Assessment section of ASHA's Practice Portal pages on Balance System Disorders and Tinnitus and Hyperacusis.
Interdisciplinary collaboration is necessary to maximize the breadth and depth of skills tested and to ensure that the individual is not over-tested or subject to practice effects due to repeated exposure to the same or similar assessment tools.
Depression or anxiety—as a consequence of neurological damage or as 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 follow-up.
The side effects of prescription drugs may affect test performance (e.g., due to excessive drowsiness). Polypharmacy—the concurrent use of several medications—is common among individuals with multiple medical conditions, and some medications may worsen cognitive problems worse.
Repetitive brain trauma contributes—along with other variables—to the development of chronic traumatic encephalopathy (CTE), which in turn influences overall cognitive and behavioral function and increases the risk for dementia (Stern et al., 2011). Therefore, consider the effects of repeated brain injury when determining prior level of function and baseline skill levels.
Periodic, ongoing assessment 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.
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 affect physical endurance and participation
- Sensory deficits (e.g., visual neglect, hearing loss)
Factors that can affect swallowing function following TBI include
- extent of brain injury;
- duration of ventilation and endotracheal intubation and/or presence of a tracheostomy;
- impairments in positioning and motor control that affect self-feeding;
- physical damage to the oral, pharyngeal, and/or laryngeal structures;
- presence of oral and/or pharyngeal sensory disorders;
- presence of oral and/or pharyngeal movement disorders; and
- cognitive impairment and behavioral dysregulation (e.g., poor memory, limited insight, impaired sequencing skills, poor judgment and reasoning, and impaired communication).
See Murdoch and Theodoros (2001) for a summary of related research.
Consider the patient's level of arousal, cognitive status, and ability to follow commands throughout ongoing swallowing 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.
Comorbidities—including memory and attention deficits, tinnitus, dizziness, and anxiety—can make it difficult to attribute auditory complaints to auditory-only processing deficits and may confound audiologic test results.
Balance is a multisensory function. Therefore, 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 et al., 2009, p. 804).
When selecting assessment tests, the SLP considers the influence of cultural and linguistic factors on the individual's communication style and the potential impact of impairment on function.
Clinicians make appropriate accommodations and modifications to the testing process to reconcile cultural and linguistic variations. Comprehensive documentation includes descriptions of these accommodations and modifications. Scores from standardized tests are often invalidated in these cases and may not be appropriate to report. Rather than reporting scores, results can be stated descriptively (e.g., number and types of errors made on various assessment tasks.) See ASHA's Practice Portal pages on Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Competence.
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 useful in identifying premorbid language proficiency, language preference for assessment and treatment of linguistic deficits, and communicative needs in the community (Lorenzen & Murray, 2008).