See the Treatment section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
Treatment of persons with TBI considers
- personal and contextual factors, such as the individual's age, education, premorbid status, social history, present social context, and vocational status (current or premorbid);
- the complex relationship between cognitive domains (e.g., the effect of attention and short-term memory deficits on new learning);
- the impact of fatigue and limited physical endurance on participation in treatment; and
- the impact of poor insight and executive function deficits on the ability to (a) recognize breakdowns in function, (b) buy into the potential benefits of treatment, and (c) adhere to specific recommendations (e.g., swallow safety guidelines).
The goal of intervention in TBI is to achieve the highest level of independent function for participation in daily living. Consistent with the ICF framework (WHO, 2001), intervention is designed to
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
- facilitate the individual's activities and participation by assisting the person in acquiring new skills and strategies; and
- modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including development and use of appropriate accommodations.
Interventions that enhance a patient's activity and participation through modification of contextual factors may be warranted, even if the prognosis for improved body structure/function is limited.
See ASHA's Person-Centered Focus on Function: Traumatic Brain Injury [PDF] for an example of goal setting consistent with ICF.
Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party respects the knowledge, skills, and experiences that the others bring to the process. This approach to care incorporates individual and family preferences and priorities and offers a range of services, including providing counseling and emotional support, providing information and resources, coordinating services, and teaching specific skills to facilitate communication.
Person- and family-centered care for individuals with TBI
- provides information to the individual, his or her family/caregivers, and other significant persons about the nature of deficits, the course of treatment, and the prognosis for recovery;
- includes the individual in collaborative decision making about self-determined goals; and
- considers input from the family/caregivers and other professionals involved in the individual's care.
See ASHA's resource on person- and family-centered care.
Treatment for TBI can be restorative and/or compensatory. These approaches are not mutually exclusive; aspects of more than one approach often are integrated into the delivery of services.
Restorative approaches involve direct therapy aimed at improving or restoring impaired function(s) through retraining. Treatment is often hierarchical, targeting specific processes in the impaired domain before introducing more demanding higher-level tasks, and eventually generalizing skills to more functional activities and tasks (Sohlberg & Mateer, 2001).
Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health [NIH], 1998). Compensatory approaches draw on the individual's strengths to maximize his or her abilities, often through the use of external or internal aids.
A compensatory approach to treatment may also include accommodations and/or modifications. Accommodations are changes to the environment, task, or mode of response that allow an individual to access and participate in an activity without changing the activity itself. Modifications are changes to the nature of an activity to facilitate participation and promote success in home, community, academic, and work settings.
The following are brief descriptions of both general and specific treatments for persons with cognitive-communication and swallowing disorders associated with TBI. This list is not exhaustive, and inclusion of any specific treatment approach does not imply endorsement by ASHA.
Augmentative and Alternative Communication (AAC)
Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech and/or writing with aided (e.g., pictures, line drawings, speech-generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. AAC may be temporary (e.g., used by patients postoperatively in intensive care) or permanent (e.g., used by an individual with a disability who will need to use some form of AAC throughout their lifetime).
Factors that influence selection and use of appropriate AAC systems following TBI include the individual's communication abilities and needs, as well as their cognitive, neurobehavioral, motor, sensory, and perceptual impairments. Individuals with TBI may rely on assistive technologies to compensate for their cognitive impairments in the absence of linguistic or motor speech disorders (Fried-Oken, Beukelman, & Hux, 2011).
See ASHA's Practice Portal page on Augmentative and Alternative Communication.
Cognitive-communication treatment may focus on restoring skills and/or compensating for deficits. Treatment can address discrete cognitive-communication domains (e.g., attention) or can focus more globally on functional communication.
Cognitive-communication treatments include the following:
- Sensory stimulation—also known as coma stimulation—is the systematic exposure of an individual in a comatose or minimally conscious state to a variety of visual, auditory, tactile, olfactory, and kinesthetic stimuli to improve arousal and level of consciousness and to prevent sensory deprivation (Giacino, Katz, & Schiff, 2006; Thomas, 2018). Sensory stimulation allows for frequent monitoring of an individual's responsiveness during recovery.
- Dual task training focuses on improving task complexity by targeting the ability to carry out two competing tasks simultaneously. Dual task training is used to restore executive functions often affected by TBI. The tasks can involve any combination of cognitive and/or motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009).
- Computer-assisted treatment (CAT) refers to the use of specially designed commercial software to improve cognitive-communication functions through repeated, structured practice of tasks related to attention, memory, problem solving, executive function, language, and speech. Software programs adapt tasks; exercises increase in difficulty as performance improves (Lebowitz, Dams-O'Connor, & Cantor, 2012). Software programs are available for use on computers, smartphones, and tablets. Computer-assisted treatment can be used and monitored by a clinician in person or remotely, thus providing consistent feedback to the individual (e.g., Politis & Norman, 2016; Teasell et al., 2013). See ASHA's resource on what to ask when evaluating any procedure, product, or program.
Instructional or teaching techniques used in cognitive-communication treatment include the following:
- Direct instruction is a comprehensive instructional technique that involves identifying target and prerequisite skills; conducting a task analysis to break skills down into smaller steps; providing models; giving consistent and immediate feedback; and providing both massed practice (longer, intensive practice sessions) and spaced/distributed practice (practice broken up into a number of smaller practice sessions).
- Strategy-based instruction focuses on the use of various strategies to improve awareness, self-monitoring, and self-regulation.
- Metacognitive skills training uses goal-setting strategies to facilitate learning and behavioral success. This training uses strategies such as self-talk, self-reflection, mental imagery, and agendas that provide feedback and track progress toward goals. See for example, Cicerone (2006) and Ownsworth, Quinn, Fleming, Kendall, and Shum (2010).
- Compensatory strategy training capitalizes on intact skills to overcome deficits resulting from TBI (Wilson, 2002). Compensatory strategies use internal aids and external aids (Shum, Fleming, Gill, Gullo, & Strong, 2011).
Internal aids are strategies used to enhance memory and executive function (de Joode, van Heugten, Verhey, & van Boxtel, 2010; Gillespie, Best, & O'Neill, 2012; Sohlberg et al., 2007; Wild, 2013). They include mnemonics; visual imagery (Kashel et al., 2002; OʼNeil-Pirozzi, Kennedy, & Sohlberg, 2015); elaborative encoding and association (Oberg & Turkstra, 1998); and chunking (Kennedy, 2006).
External aids are used to improve attention, time management, organization, and recall of events and information (Burns, 2004; Teasell et al., 2013). Computers and handheld devices, including smartphones and voice recorders, can be used as functional external aids. Low-tech options include calendars, timers, checklists, maps, color-coded binders, and small notebooks (Burns, 2004; DePompei et al., 2008).
- Errorless learning is an instructional technique that tries to minimize errors as the individual learns a new skill (Ownsworth et al., 2013). Errorless learning involves task analysis to break skills down into smaller steps, modeling before the first attempt at performing the task, giving immediate corrective feedback, and carefully fading supports and prompts (Sohlberg, Ehlhardt, & Kennedy, 2005; Sohlberg & Turkstra, 2011). Spaced/distributed practice may facilitate errorless learning (Melton & Bourgeois, 2005). Errorless learning is most helpful for individuals with relatively unimpaired procedural memory (memory of how to perform certain procedures) and severely impaired declarative memory (memory of facts and events).
Social Communication Interventions
Social communication interventions are designed (a) to improve functional conversational skills, including the use of appropriate pragmatic language norms (e.g., taking turns and remaining on topic) and (b) to help the individual with TBI navigate social situations.
Components of social communication intervention in adults with TBI include
- sharing knowledge with, and training, everyday communication partners;
- situational training to improve social perception and the ability to interpret others' behavior;
- situational coaching prior to challenging situations; and
- counseling to help an individual identify a sense of self that includes positive social interaction strategies (Ylvisaker, Turkstra, & Coelho, 2005). See also ASHA's Practice Portal page on Counseling for Professional Service Delivery.
Communication partner training (CPT) is an example of social communication intervention. The goal of CPT is to improve the communication effectiveness of individuals with TBI by training communication partners to use strategies such as
- providing emotional support;
- using a positive question style;
- using collaborative turn-taking; and
- helping the individual with TBI extend and organize their thinking (e.g., Sim, Power, & Togher, 2013; Togher, McDonald, Tate, Power, & Rietdijk, 2013).
See also ASHA's Practice Portal page on Social Communication Disorder.
Speech and Voice
TBI can result in dysarthria and apraxia, as well as problems with respiration, phonation, and resonance. Intervention may focus on the individual speech subsystems of respiration, phonation, articulation, and velopharyngeal function or, more globally, on overall verbal communication function using behavioral and instrumental treatments, compensatory strategies, and/or environmental modifications.
See ASHA's Practice Portal pages on Dysarthria in Adults, Acquired Apraxia of Speech, Voice Disorders, and Resonance Disorders.
The goal of dysphagia treatment is to support safe and efficient oral intake and to ensure adequate nutrition and hydration.
Considerations for dysphagia management in individuals with TBI include
- cognitive-linguistic deficits (e.g., auditory processing and memory loss) that can affect learning, recall, and use of compensatory swallowing;
- neurobehavioral deficits (e.g., impulsivity, agitation);
- perceptual deficits (e.g., visual field neglect);
- physical limitations that can affect motor control and posture; and
- sensory impairments that can affect oral intake and swallow safety.
Effective dysphagia management relies on the consistent implementation of compensatory strategies. Deficits in any of the areas noted above can have a negative impact on the success of treatment.
See ASHA's Practice Portal page on Adult Dysphagia.
Hearing and Balance
Audiologists are integral to rehabilitation of hearing and balance deficits associated with TBI. Treatment for hearing loss includes selection and fitting of amplification devices and training in the use of assistive technologies (e.g., hearing assistive technology [HATS]).
The treatment goals for balance disorders associated with TBI are (a) to promote the central nervous system's natural compensation processes to reduce or eliminate symptoms, (b) to decrease the individual's sensitivity to symptom-provoking movements, and (c) to reduce the risk of falls.
Audiologists are also involved in the management of tinnitus associated with TBI. Management can include the use of hearing aids, sound masking, counseling, and cognitive-behavioral interventions.
Treatment for audiology-related symptoms may include counseling about the use of coping and compensatory skills that can minimize the effects of hearing and balance disorders and reduce safety risks.
See ASHA's Practice Portal pages on Hearing Loss—Beyond Early Childhood, Hearing Aids for Adults, Balance System Disorders, and Tinnitus and Hyperacusis. See also ASHA's resources titled Hearing Assistive Technology (HATS) and Audiology Information Series: Hearing Assistive Technology.
Treatment considers the cultural values and norms of the individual. Different dimensions of culture may influence an individual's views on seeking care and external support following a TBI (see ASHA's resource on examples of cultural dimensions). For example, some cultures may have a sense of shame or feel the need to hide a disability. This may influence how an individual and their family/caregivers approach treatment. See ASHA's Practice Portal page on Cultural Competence.
Treatment is also sensitive to linguistic diversity. It is provided in the language(s) used by the individual with TBI. See ASHA's Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators.
Individuals with persistent cognitive-communication deficits after a TBI may continue to face challenges as they return to work or academic settings and manage daily activities such as shopping and handling finances (e.g., Colantonio et al., 2004; Kennedy, Krause, & Turkstra, 2008; Meulenbroek, Bowers, & Turkstra, 2016; Meulenbroek & Turkstra, 2016).
The potential impact of persisting deficits highlights the need for continued support. The role of the SLP is to identify communication-related deficits, determine how they might affect the individual in various settings, and design treatment approaches to minimize the impact of these deficits.
Considerations in Work Settings
The nature of deficits associated with TBI creates unique challenges in work settings. Fatigue, sensory issues, health concerns, and cognitive-communication deficits (e.g., language processing, reading and writing, verbal reasoning, memory, and pragmatics) can have a negative impact on performance (see, e.g., Meulenbroek et al., 2016; Meulenbroek & Turkstra, 2016).
The SLP identifies current cognitive-communication deficits, determines how these may affect life skills and job performance, and then trains the individual on strategies they can use to minimize the impact of the deficits in work settings (Bonelli, Ritter, & Kinsler, 2007). The SLP collaborates with counselors and psychologists, vocational rehabilitation specialists, job coaches, and employers, as appropriate, to help implement necessary accommodations for maximum outcomes.
Individuals with TBI may be eligible for protections in the workplace under Section 504 of the Rehabilitation Act of 1973. This law protects a qualified individual from discrimination based on their disability. Section 504 prohibits employment discrimination against individuals who meet job requirements and can perform essential job duties with or without reasonable accommodations. It may also provide vocational training and employment services for eligible individuals. SLPs can give input about reasonable accommodations to minimize the effects of cognitive-communication deficits. These include providing written task instructions and using time management devices to help the individual stay on task.
Considerations in Academic Settings
Attention, memory, learning, executive function, and social–emotional impairments—coupled with self-regulation challenges—place individuals with TBI at greater risk for failure in academic settings (Kennedy et al., 2008).
The SLP can provide support to individuals in college (and vocational training programs) by identifying systems and services to facilitate studying, learning, and time management, and by training individuals to use compensatory strategies and promoting self-advocacy (Kennedy & Krause, 2011; Turkstra, Gamazon-Waddell, & Evans, 2004; Volkers, 2015).
Disability support services staff may collaborate with SLPs to select courses, modify schedules, and implement accommodations (under Section 504 or similar plans, if applicable). Accommodations might include notetakers, extended time for tests and assignments, and assistive technology (e.g., text-to-speech and speech-to-text devices that help with reading and writing tasks).
See the Service Delivery section of the Traumatic Brain Injury (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the optimal treatment approaches for individuals with TBI, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may affect treatment outcomes.
Format is the structure of the treatment session (e.g., group vs. individual). Group therapy can provide individuals with TBI an opportunity to initiate social interaction in a structured environment with feedback from the clinician and peers. The combination of individual and group therapy is more effective in reaching functional goals than the group format alone (Tate et al., 2014).
Technology has been incorporated into the delivery of services for TBI, including the use of telepractice to deliver face-to-face services remotely. Videoconferencing and interactive skills-based programs via telepractice may be more meaningful for providing support and information to caregivers than self-guided web sessions (Rietdijk, Togher, & Power, 2012). Telepractice may allow clinicians to help patients practice skills in the context in which those skills will be used (Turkstra, Quinn-Padron, Johnson, Workinger, & Antoniotti, 2012). See ASHA's Practice Portal Page on Telepractice.
Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). Cognitive rehabilitation is most successful in the context of the individual's needs and current living environment. Family members and significant others play a critical role in supporting the individual with TBI and augmenting the treatment plan. Training that incorporates everyday communication partners may allow partners to facilitate carryover beyond the training sessions (Togher et al., 2014).
Dosage refers to the frequency, intensity, and duration of service. Clinicians consider the individual's arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity when determining the appropriate frequency, intensity, and duration of services.
Timing refers to the timing of intervention relative to the injury. Treatment typically begins with assessment in the acute or rehabilitation inpatient setting and may continue in post-acute care (e.g., post-acute rehabilitation).
Setting refers to the location of treatment (e.g., home, community-based). Clinicians consider the individual's functional abilities and goals and how best to facilitate carryover when determining the most appropriate setting for intervention. Time-limited residential programs and community-based programs are available in some areas to foster community integration and provide peer support.