See the Traumatic Brain Injury (Adults) Evidence Map for summaries of the available research on this topic.
The scope of this page is limited to traumatic brain injury in adults (ages 18 years and older). For information about traumatic brain injury in children (ages birth through 21), see ASHA's Practice Portal page on Pediatric Traumatic Brain Injury.
Traumatic brain injury (TBI) is a form of nondegenerative acquired brain injury, resulting from an external physical force to the head (e.g., fall) or other mechanisms of displacement of the brain within the skull (e.g., blast injuries). Consistent with the diagnostic criteria detailed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), TBI is associated with one or more of the following characteristics:
TBI can cause brain damage that is focal (e.g., gunshot wound) or widespread (e.g., diffuse axonal injury sustained in a motor vehicle accident). Damage can result from a primary injury or a secondary injury (see common classifications of TBI for more details).
Severity of TBI is based on the extent and nature of the injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and extent of confusion at initial assessment during the acute phase of the injury (APA, 2013; Centers for Disease Control and Prevention [CDC], 2015).
The Department of Defense (DOD) defines the following levels of severity (Defense Health Agency, 2019):
Incidence refers to the number of new cases identified in a specific time period.
Prevalence refers to the number of individuals who are living with TBI in a given time period.
Worldwide, in 2016, there were approximately 27 million new cases of TBI with an age-adjusted incidence rate of 369 per 100,000—representing a 3.6% increase from 1990. In the same year, prevalence was 55.5 million individuals, representing an 8.4% increase from 1990 (Global Burden of Disease [GBD], 2019). Each year, the number of new cases of TBI in the Unites States is approximately 2.8 million (CDC, 2015). These incidence rates include approximately 2.5 million TBI-related emergency department visits, 288,000 TBI-related hospitalizations, and 57,000 TBI-related deaths. Whereas age-adjusted rates of TBI-related ED visits increased by 54% over the span of 8 years (2006–2014), hospitalization rates decreased by 8% and death rates decreased by 6% (CDC, 2014).
According to the National Center for Injury Prevention and Control, an estimated cumulative 5.3 million individuals are living with a TBI-related disability in the United States. This represents a prevalence of approximately 2% of the U.S. population (CDC, 2015). Additional data suggest the prevalence of U.S. TBI-related disability after hospitalization to be 3.2 million (Zaloshnja, Miller, Langlois, & Selassie, 2008). Current studies estimate that approximately 775,000 older adults live with long-term disability associated with TBI (Zaloshnja et al., 2008).
Incidence and prevalence rates of TBI vary across clinical and epidemiological studies. These variations are often due to differences in participant characteristics (e.g., ages included), diagnostic classification criteria within and across subtypes (e.g., mild TBI vs. severe TBI), and sources of data (e.g., hospital admissions, emergency room visits, general practitioner visits). Moreover, current statistics do not consider individuals who do not seek medical care. Therefore, these estimates may significantly underestimate the incidence and prevalence of TBI.
The TBI prevalence in the general population is 16.7% among males and 8.5% among females. The odds of sustaining a TBI are 2.22 times higher in men than in women (Frost, Farrer, Primosch, & Hedges, 2012). Overall, males account for approximately 59% of all reported TBI-related medical visits in the United States (Faul, Xu, Wald, & Coronado, 2010).
As many as 75% of individuals who experience a TBI are diagnosed with mild TBI. This is likely an underestimate of the problem, as patients with mild TBI—who are often treated outside the hospital setting or are not treated at all—are not included in most estimates. In addition, this number includes only mild TBIs in the civilian population (CDC, 2003). It is believed that factors such as automobile safety, seatbelt use, helmet use, and better overall treatment for severe TBI in prehospital and hospital settings, while unable to prevent TBIs entirely, have mitigated the severity and thus mortality (Thurman et al., 1999).
Signs and symptoms of TBI vary, depending on the site and extent of injury to the brain, premorbid abilities, and functional domains affected (e.g., physical, cognitive, language, sensory). The effects of TBI can be temporary or permanent, and no two individuals present with the same pattern.
The clinician considers cultural differences that may lead to differences in presentation of certain cognitive measures (e.g., response time, self-monitoring, executive functioning). See ASHA's Practice Portal page on Cultural Responsiveness for more information.
Auditory and Vestibular
Other Sensory–Perceptual Sequelae
Memory and Learning
Other Cognitive Deficits
See ASHA's Practice Portal page on Voice Disorders.
See ASHA's Practice Portal pages on Adult Dysphagia.
Cognitive control deficits have a unique impact on the linguistic abilities in bilingual and multilingual speakers (Ansaldo & Marcotte, 2007), especially in individuals with frontal lobe and subcortical lesions (Price, Green, & von Studnitz, 1999). The individual's premorbid proficiency in the languages they speak can influence their ability to maintain the target language.
In addition to language production errors found in monolingual speakers, bilingual and multilingual individuals with acquired brain injury may also demonstrate
Speech-language pathologists (SLPs) consider variations in narrative structures secondary to cultural and linguistic factors to ensure that a communication difference is not inaccurately diagnosed as a disorder.
The CDC (2019) identified the following leading causes:
Falls were the leading cause of hospitalizations among adults 55 years of age and older (CDC, 2014). Motor vehicle accidents were the leading cause of hospitalizations for adolescents and adults aged 15–44 years of age. Persons aged 15–24 years and 75 years and older are at highest risk of sustaining a TBI, with the most common causes attributed to motor vehicle crashes, falls, and violence (CDC, 2014; Faul et al., 2010).
Sports-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 symptoms of the first have resolved completely; the second impact is more likely to cause brain swelling and widespread damage (Dessy, Rasouli, & Choudhri, 2015). See ASHA's resource on common classifications of TBI.
Speech-language pathologists (SLPs) play a central role in the screening, assessment, and treatment of persons with TBI. The professional roles and activities in speech-language pathology include clinical services (assessment, planning, and treatment), prevention, and advocacy, as well as education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in individuals with TBI. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include the following:
As indicated in the Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
Successful management of individuals with TBI typically requires collaboration and teaming with other professionals. For example, dysphagia management may include interdisciplinary teamwork between occupational therapists, dietitians, nursing staff, and the SLP. SLPs may also work with nursing staff (e.g., to facilitate communication between the individual and their medical team) and with physical therapists (e.g., to promote carryover and insight for current limitations and safety).
Interdisciplinary collaboration and teaming also form an integral part of audiology services to individuals with TBI. Audiologists consult and collaborate regularly with other professionals about the individual's communication management, accessibility to information, the vocational/educational implications of hearing loss and balance problems, and the legal implications of hearing loss and/or other auditory and vestibular dysfunction.
See ASHA's web page on interprofessional education/interprofessional practice (IPE/IPE) and ASHA's resource on collaboration and teaming.
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 Responsiveness, 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 in Adults, Tinnitus and Hyperacusis, and Balance System Disorders.
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 they 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 in Adults.
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:
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
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
(Fausti, Wilmington, Gallun, Myers, & Henry, 2009; Wintrow, 2013)
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:
Factors that can affect swallowing function following TBI include
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 Responsiveness.
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).
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
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
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
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) 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:
Instructional or teaching techniques used in cognitive-communication treatment include the following:
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
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
See also ASHA's Practice Portal page on Social Communication Disorder.
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.
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
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.
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 in Adults, 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 Responsiveness.
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.
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.
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.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/
Ansaldo, A. I., & Marcotte, K. (2007). Language switching and mixing in the context of bilingual aphasia. In J. G. Centeno, L. K. Obler, & R. T. Anderson (Eds.), Studying communication disorders in Spanish speakers: Theoretical, research, and clinical aspects (pp. 12–21). Clevedon, United Kingdom: Multilingual Matters.
Bonelli, P., Ritter, P., & Kinsler, E. (2007, November). The speech-language pathologist's role in vocational outcomes. Poster session presented at the annual convention of the American Speech-Language-Hearing Association, Boston, MA.
Burns, M. S. (2004). Speech-language pathology management of TBI in school-aged children. Perspectives on School-Based Issues, 5, 14–19.
Centers for Disease Control and Prevention. (2003). Report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem. Atlanta, GA: National Center for Injury Prevention and Control. Retrieved from https://www.cdc.gov/traumaticbraininjury/pdf/mtbireport-a.pdf
Centers for Disease Control and Prevention. (2014). Traumatic brain injury in the United States: Fact sheet. Retrieved from www.cdc.gov/traumaticbraininjury/get_the_facts.html
Centers for Disease Control and Prevention. (2015). Report to Congress on traumatic brain injury in the United States: Epidemiology and rehabilitation. Atlanta, GA: Author. Retrieved from https://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab-a.pdf
Centers for Disease Control and Prevention. (2019). Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2014. Atlanta, GA: Author. Retrieved from https://stacks.cdc.gov/view/cdc/78062
Cicerone, K. D. (2006). Cognitive rehabilitation. In N. D. Zasler, D. I. Katz, & R. D. Zafonte (Eds.), Brain injury medicine: Principles and practice (pp. 1061–1084). New York, NY: Demos Medical Publishing.
Coelho, C., Ylvisaker, M., & Turkstra, L. (2005). Non-standardized assessment approaches for individuals with cognitive-communication disorders. Seminars in Speech and Language, 26,223–241.
Colantonio, A., Ratcliff, G., Chase, S., Kelsey, S., Escobar, M., & Vernich, L. (2004). Long term outcomes after moderate to severe traumatic brain injury. Disability and Rehabilitation, 26,253–261.
de Joode, E., van Heugten, C., Verhey, F., & van Boxtel, M. (2010). Efficacy and usability of assistive technology for patients with cognitive deficits. Clinical Rehabilitation, 24, 701–714.
Defense Health Agency. (2019). DoD Standard surveillance case definition for TBI: Adapted for the Armed Forces Health Surveillance Branch (AFHSB). Arlington, VA: Author.
DePompei, R., Gillette, Y., Goetz, E., Xenopoulos-Oddsson, A., Bryen, D., & Dowds, M. (2008). Practical applications for use of PDAs and smartphones with children and adolescents who have traumatic brain injury. NeuroRehabilitation, 23, 487–499.
Dessy, A. M., Rasouli, J., & Choudhri, T. F. (2015). Second impact syndrome: A rare, devastating consequence of repetitive head injuries. Neurosurgery Quarterly, 25, 423–426.
Evans, J. J., Greenfield, E., Wilson, B. A., & Bateman, A. (2009). Walking and talking therapy: Improving cognitive-motor dual-tasking in neurological illness. Journal of the International Neuropsychological Society, 15, 112–120.
Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002–2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Fausti, S. A., Wilmington, D. J., Gallun, F. J., Myers, P. J., & Henry, J. A. (2009). Auditory and vestibular dysfunction associated with blast-related traumatic brain injury. Journal of Rehabilitation Research and Development, 46, 797–810.
Fried-Oken, M., Beukelman, D., & Hux, K. (2011). Current and future AAC research considerations for adults with acquired cognitive and communication impairments. Assistive Technology, 24, 56–66.
Frost, R., Farrer, T., Primosch, M., & Hedges, D. (2013). Prevalence of traumatic brain injury in the general adult population: A meta-analysis. Neuroepidemiology, 40, 154–159.
Giacino, J. T., Katz, D. I., & Schiff, N. (2006). Assessment and rehabilitative management of individuals with disorders of consciousness. In N. D. Zasler, D. I. Katz, & R. D. Zafonte (Eds.), Brain injury medicine: Principles and practice (pp. 423–442). New York, NY: Demos Medical Publishing.
Gillespie, A., Best, C., & O'Neill, B. (2012). Cognitive function and assistive technology for cognition: A systematic review. Journal of the Neuropsychological Society, 18, 1–19.
Global Burden of Disease 2016 Traumatic Brain Injury and Spinal Cord Collaborators. (2019). Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet, 18, 56–87.
Hegde, M. N. (2018). A coursebook on aphasia and other neurogenic language disorders. San Diego, CA: Plural Publishing.
Kashel, R., Sala, S. D., Cantagallo, A., Fahlbock, A., Laaksonen, R., & Kazen, M. (2002). Imagery mnemonics for the rehabilitation of memory: A randomized group controlled trial. Neuropsychological Rehabilitation, 12, 127–153.
Kennedy, M. R. T. (2006, October). Managing memory and metamemory impairments in individuals with traumatic brain injury. The ASHA Leader, 11, 8–36.
Kennedy, M. R. T., & Krause, M. O. (2011). Self-regulated learning in a dynamic coaching model for supporting college students with traumatic brain injury: Two case reports. The Journal of Head Trauma Rehabilitation, 26, 212–223.
Kennedy, M. R. T., Krause, M. O., & Turkstra, L. S. (2008). An electronic survey about college experiences after traumatic brain injury. NeuroRehabilitation, 23, 511–520.
Lebowitz, M. S., Dams-O'Connor, K., & Cantor, J. B. (2012). Feasibility of computerized brain plasticity-based cognitive training after traumatic brain injury. Journal of Rehabilitation Research and Development, 49, 1547–1556.
Logemann, J. A. (2006). Medical and rehabilitative therapy of oral, pharyngeal motor disorders. GI Motility online. Retrieved from www.nature.com/gimo/contents/pt1/full/gimo50.html
Lorenzen, B., & Murray, L. L. (2008). Bilingual aphasia: A theoretical and clinical review. American Journal of Speech-Language Pathology, 17, 299–317.
Melton, A., & Bourgeois, M. (2005). Training compensatory memory strategies via the telephone for persons with TBI. Aphasiology, 19, 353–364.
Meulenbroek, P., Bowers, B., & Turkstra, L. S. (2016). Characterizing common workplace communication skills for disorders associated with traumatic brain injury: A qualitative study. Journal of Vocational Rehabilitation, 44, 15–31.
Meulenbroek, P., & Turkstra, L. S. (2016). Job stability in skilled work and communication ability after moderate–severe traumatic brain injury. Disability and Rehabilitation, 38, 452–461.
Morgan, A., Ward, E., & Murdoch, B. (2004). Clinical progression and outcome of dysphagia following paediatric traumatic brain injury: A prospective study. Brain Injury, 18, 359–376.
Murdoch, B. E., & Theodoros, D. G. (2001). Traumatic brain injury: Associated speech, language, and swallowing disorders. Clifton Park, NY: Cengage Learning.
National Institutes of Health. (1998). Rehabilitation of persons with traumatic brain injury [NIH Consensus Statement]. Bethesda, MD: Author.
Oberg, L., & Turkstra, L. (1998). Use of elaborative encoding to facilitate verbal learning after adolescent traumatic brain injury. The Journal of Head Trauma Rehabilitation, 13, 44–62.
OʼNeil-Pirozzi, T. M., Kennedy, M. R., & Sohlberg, M. M. (2015). Evidence-based practice for the use of internal strategies as a memory compensation technique after brain injury: A systematic review. The Journal of Head Trauma Rehabilitation, 31, e1–e11.
Ownsworth, T., Fleming, J., Tate, R., Shum, D. H., Griffin, J., Schmidt, J., . . . Chevignard, M. (2013). Comparison of error-based and errorless learning for people with severe traumatic brain injury: Study protocol for a randomized control trial. Trials, 14, Article number 369.
Ownsworth, T., Quinn, H., Fleming, J., Kendall, M., & Shum, D. (2010). Error self-regulation following traumatic brain injury: A single case study evaluation of metacognitive skills training and behavioural practice interventions. Neuropsychological Rehabilitation, 20,59–80.
Penn, C., Frankel, T., Watermeyer, J., & Russell, N. (2010). Executive function and conversational strategies in bilingual aphasia. Aphasiology, 24, 288–308.
Politis, A. M., & Norman, R. S. (2016). Computer-based cognitive rehabilitation for individuals with traumatic brain injury: A systematic review. Perspectives of the ASHA Special Interest Groups, 1(2), 18–46.
Price, C. J., Green, D. W., & von Studnitz, R. (1999). A functional imaging study of translation and language switching. Brain, 122,2221–2235.
Rehabilitation Act of 1973, Section 504, P.L. 93-112, 29 U.S.C. § 701 et seq.
Rietdijk, R., Togher, L., & Power, E. (2012). Supporting family members of people with traumatic brain injury using telehealth: A systematic review. Journal of Rehabilitation Medicine, 44, 913–921.
Shum, D., Fleming, J., Gill, H., Gullo, M. J., & Strong, J. (2011). A randomized controlled trial of prospective memory rehabilitation in adults with traumatic brain injury. Journal of Rehabilitation Medicine, 43, 216–223.
Sim, P., Power, E., & Togher, L. (2013). Describing conversations between individuals with traumatic brain injury (TBI) and communication partners following communication partner training: Using exchange structure analysis. Brain Injury, 27, 717–742.
Sohlberg, M. M., Ehlhardt, L., & Kennedy, M. (2005). Instructional techniques in cognitive rehabilitation: A preliminary report. Seminars in Speech and Language, 26, 268–279.
Sohlberg, M. M., Kennedy, M., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence based practice for the use of external aids as a memory rehabilitation technique. Journal of Medical Speech-Language Pathology, 15, xv–li.
Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York, NY: Guilford.
Sohlberg, M. M., & Turkstra, L. S. (2011). Optimizing cognitive rehabilitation: Effective instructional methods. New York, NY: Guilford.
Stern, R. A., Riley, D. O., Daneshvar, D. H., Nowinski, C. J., Cantu, R. C., & McKee, A. C. (2011). Long-term consequences of repetitive brain trauma: Chronic traumatic encephalopathy. Physical Medicine & Rehabilitation, 3, S460–S467.
Tate, R., Kennedy, M., Ponsford, J., Douglas, J., Velikonja, D., Bayley, M., & Stergiou-Kita, M. (2014). INCOG recommendations for management of cognition following traumatic brain injury, Part III: Executive function and self-awareness. The Journal of Head Trauma Rehabilitation, 29, 338–352.
Teasell, R., Marshall, S., Cullen, N., Bayley, B., Rees, L. Weiser, M., . . . Aubut, J. (2013). Evidence-based review of moderate to severe acquired brain injury: Executive summary. Toronto, Ontario, Canada: Ontario Neurotrauma Foundation.
Thomas, C. (2018). Low awareness conditions: Their assessment and treatment. In G. Newby, R. Coetzer, A. Daisley, & S. Weatherhead (Eds.), Practical neuropsychological rehabilitation in acquired brain injury: A guide for working clinicians (pp. 159–178). New York, NY: Routledge.
Thurman, D. J., Alverson, C., Browne, D., Dunn, K. A., Guerrero, J., Johnson, R., . . . Toal, S. (1999). Traumatic brain injury in the United States: A report to Congress. Atlanta, GA: Centers for Disease Control and Prevention.
Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk, R. (2013). Training communication partners of people with severe traumatic brain injury improves everyday conversations: A multicenter single blind clinical trial. Journal of Rehabilitation Medicine, 45, 637–645.
Togher, L., Wiseman-Hakes, C., Douglas, J., Stergiou-Kita, M., Ponsford, J., Teasell, R., . . . Turkstra, L. (2014). INCOG recommendations for management of cognition following traumatic brain injury, Part IV: Cognitive communication. The Journal of Head Trauma Rehabilitation, 29, 353–368.
Turkstra, L. S., Gamazon-Waddell, Y., & Evans, J. (2004). Traumatic brain injury and post-secondary education. Perspectives on Neurophysiology and Neurogenic Speech and Language, 14(3), 19–24. Retrieved from https://pubs.asha.org/doi/10.1044/nnsld14.3.19
Turkstra, L. S., Quinn-Padron, M., Johnson, J. E., Workinger, M. S., & Antoniotti, N. (2012). In-person versus telehealth assessment of discourse ability in adults with traumatic brain injury. The Journal of Head Trauma Rehabilitation, 27, 424–432.
Volkers, N. (2015, December). Back to school—with a TBI: New campus programs spearheaded by speech-language pathologists aim to help students get their academics back on track. The ASHA Leader, 20(12), 46–50. Retrieved from https://doi.org/10.1044/leader.FTR2.20122015.46
Wild, M. R. (2013). Assistive technology for cognition following brain injury: Guidelines for device and app selection. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 23(2), 49–58. Retrieved from https://pubs.asha.org/doi/10.1044/nnsld23.2.49
Wilson, B. (2002). Management and remediation of memory problems in brain-injured adults. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The handbook of memory disorders (pp. 617–636). Chichester, West Sussex, England: Wiley.
Wintrow, S. (2013). The auditory and vestibular consequences of traumatic brain injury and the role of the audiologist on the interdisciplinary management team (Unpublished capstone project). Ohio State University, Columbus.
World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva, Switzerland: Author.
Ylvisaker, M., Turkstra, L., & Coelho, C. (2005). Behavioral and social interventions for individuals with traumatic brain injury: A summary of the research with clinical implications. Seminars in Speech and Language, 26, 256–267.
Zaloshnja, E., Miller, T., Langlois, J. A., & Selassie, A. W. (2008). Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. The Journal of Head Trauma Rehabilitation, 23, 394–400.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Traumatic Brain Injury page.
In addition, ASHA thanks the members of the Ad Hoc Joint Committee on Interprofessional Relationships of the ASHA and Division 40 (Clinical Neuropsychology) of the American Psychological Association (APA); the Ad Hoc Committee on Interprofessional Relationships Neuropsychology; and the Working Group on Cognitive-Communication Disorders of ASHA’s Special Interest Division 1, Language Learning and Education; and Division 2, Neurogenic Communication Disorders whose work was foundational to the development of this content.
The members of the Ad Hoc Joint Committee on Interprofessional Relationships of the ASHA and Division 40 (Clinical Neuropsychology) of the American Psychological Association (APA) included ASHA representatives Pelagie Beeson, Susan Ellis Weismer, Audrey Holland, Susan Langmore, Lynn Maher, Mark Ylvisaker, and Diane Brown (ex officio). Alex F. Johnson served as monitoring vice president. APA representatives included Kenneth Adams, Sharon Brown, Jill Fischer, Robin Hanks, Doug Johnson-Greene, Sanford Pederson, Steven Putnam, and Joseph H. Ricker. 2006-07 members of the Joint Committee included Anastasia (Stacie) Raymer, Fofi Constantinidou, Wendy Ellmo, Lyn Turkstra, and Diane Paul (ex officio). APA representatives in 2006-07 included Angelle Sander, Risa Nakase-Richardson, Mary Kay Pavol, Tresa Roebuck Spencer, and Jeffrey Wertheimer. Brian B. Shulman served as monitoring vice president.
The members of the Ad Hoc Committee on Interprofessional Relationships Neuropsychology included Leslie J. Gonzalez Rothi (chair), Brenda L. Adamovich, Craig W. Linebaugh, Richard K. Peach and Lynette Goldberg (ex officio). Ann Carey served as monitoring vice president. Representatives of the Division of Clinical Neuropsychology (Division 40) of the American Psychological Association included Kenneth M. Adams, Linas Bieliauskas, Robert A. Bornstein, Gerald Goldstein, Byron P. Rourke.
The Working Group on Cognitive-Communication Disorders of ASHA’s Special Interest Division 1, Language Learning and Education; and Division 2, Neurogenic Communication Disorders included Leora Cherney, Ron Gillam, Mary Kennedy, Lynn M. Maher (chair), Dava Waltzman, Mark Ylvisaker, and Diane Paul (ex officio). Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000-2002 and 2003-2005, respectively.)
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Traumatic Brain Injury in Adults (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Traumatic-Brain-Injury-in-Adults/.