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Assessment of Cognitive-Communicative Disorders of Mild Traumatic Brain Injury Sustained in Combat

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Abstract

Background: Mild traumatic brain injury (mTBI) is recognized as the signature injury of the current conflicts in Iraq and Afghanistan, yet there remains limited understanding of the persisting cognitive deficits of mTBI sustained in combat. Speech-language pathologists (SLPs) have traditionally been responsible for evaluating and treating the cognitive-communication disorders following severe brain injuries. The evaluation instruments historically used are insensitive to the subtle deficits found in individuals with mTBI. Objectives: Based on the limited literature and clinical evidence describing traditional and current tests for measuring cognitive-communication deficits (CCD) of TBI, the strengths and weaknesses of the instruments are discussed relative to their use with mTBI. It is necessary to understand the nature and severity of CCD associated with mTBI for treatment planning and goal setting. Yet, the complexity of mTBI sustained in combat, which often co-occurs with PTSD and other psychological health and physiological issues, creates a clinical challenge for speech-language pathologists worldwide. The purpose of the paper is to explore methods for substantiating the nature and severity of CCD described by service members returning from combat. Methods: To better understand the nature of the functional cognitive-communication deficits described by service members returning from combat, a patient questionnaire and a test protocol were designed and administered to over 200 patients. Preliminary impressions are described addressing the nature of the deficits and the challenges faced in differentiating the etiologies of the CCD. Conclusions: Speech-language pathologists are challenged with evaluating, diagnosing, and treating the cognitive-communication deficits of mTBI resulting from combat-related injuries. Assessments that are sensitive to the functional deficits of mTBI are recommended. An interdisciplinary rehabilitation model is essential for differentially diagnosing the consequences of mTBI, PTSD, and other psychological and physical health concerns.
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Assessment of Cognitive-Communicative Disorders of Mild
Traumatic Brain Injury Sustained in Combat
Christine Parrish, Carole Roth, Brooke Roberts, Gail Davie
Division of Speech Pathology, Department of Otolaryngology
Naval Medical Center
San Diego, CA
The views expressed in this article are those of the authors and do not reflect the official
policy or position of the Department of the Navy, Department of Defense, or the United States
Government.
Abstract
Background: Mild traumatic brain injury (mTBI ) is recognized as the signature injury of
the current conflicts in Iraq and Afghanistan, yet there remains limited understanding of
the persisting cognitive deficits of mTBI sustained in combat. Speech-language
pathologists (SLPs) have traditionally been responsible for evaluating and treating the
cognitive-communication disorders following severe brain injuries. The evaluation
instruments historically used are insensitive to the subtle deficits found in individuals
with mTBI.
Objectives: Based on the limited literature and clinical evidence describing traditional and
current tests for measuring cognitive-communication deficits (CCD) of TBI, the strengths
and weaknesses of the instruments are discussed relative to their use with mTBI. It is
necessary to understand the nature and severity of CCD associated with mTBI for
treatment planning and goal setting. Yet, the complexity of mTBI sustained in combat,
which often co-occurs with PTSD and other psychological health and physiological issues,
creates a clinical challenge for speech-language pathologists worldwide. The purpose of
the paper is to explore methods for substantiating the nature and severity of CCD
described by service members returning from combat.
Methods: To better understand the nature of the functional cognitive-communication
deficits described by service members returning from combat, a patient questionnaire and
a test protocol were designed and administered to over 200 patients. Preliminary
impressions are described addressing the nature of the deficits and the challenges faced
in differentiating the etiologies of the CCD.
Conclusions: Speech-language pathologists are challenged with evaluating, diagnosing,
and treating the cognitive-communication deficits of mTBI resulting from combat-related
injuries. Assessments that are sensitive to the functional deficits of mTBI are
recommended. An interdisciplinary rehabilitation model is essential for differentially
diagnosing the consequences of mTBI, PTSD, and other psychological and physical health
concerns.
Brain injury is well recognized as the signature injury of the Global War on Terror
(GWOT), as most service members are surviving significant blast-induced injuries due to
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advances in body armor and head protection (Hoge et al., 2008; Okie, 2005). While there is a
wealth of literature describing the cognitive-communication impairments caused by severe
brain injuries resulting from falls, assaults, and motor vehicle accidents, many of the soldiers,
sailors and Marines returning from the GWOT have been diagnosed with mild traumatic brain
injuries (mTBI) following single or multiple blast exposures in combat. As wounded service
members and veterans recover and return to their military and civilian communities, speech-
language pathologists (SLPs) will be treating them for cognitive-communication problems.
Therefore, it is imperative to understand the nature and severity of their problems in an effort
to address their rehabilitative, social, educational, and vocational needs.
Cognitive-Communication Deficits
Cognitive-communication disorders encompass difficulty with any aspect of
communication that is affected by disruption of cognition (ASHA, 2005a, 2005b). The cognitive-
communication deficits (CCD) following mTBI sustained in combat are not well understood.
What little is known suggests that the CCD in this population are multi-factorial in nature.
Combat-acquired brain injury often occurs in the presence of highly stressful experiences that
can result in debilitating psycho-pathological reactions, leading to persisting psychological
symptoms such as post-traumatic stress disorder (PTSD), depression, anxiety, and adjustment
disorders (Glaesser, Neuner, Lutgehetmann, Schmidt, & Elbert, 2004). In fact, PTSD has been
associated with mTBI in as many as 71% of soldiers sustaining altered or loss of consciousness
(Hoge et al., 2008). The combination of mTBI and psychological health issues complicates
accurate assessment and diagnosis of cognitive-communication abilities, due to the
overlapping symptoms of PTSD and mTBI (Danckwerts & Leathem, 2003; Roth, 2007). The
purpose of this paper is to describe our experience evaluating the cognitive-communication
abilities of combat-injured service members returning from Iraq and Afghanistan.
Advancements in the identification of individuals with mTBI have evolved from the
battlefield to military treatment facilities (MTFs) in the United States, such as Walter Reed
Army Medical Center and Naval Medical Center San Diego, since the onset of the GWOT.
Improved recognition of the signs of mTBI is the result of new screening measures and
extensive education regarding brain injury provided at multiple levels including forward
surgical teams in theater, combat support hospitals, and level IV military hospitals (e.g., Army
Hospital, Landstuhl, Germany). Early detection of the symptoms of mTBI has been promoted at
all levels of military medical care, resulting in more immediate evaluation and treatment of
mTBI than ever before. Furthermore, the military has made a concerted effort to recognize the
presence of persisting CCD related to previous deployments dating as far back as the beginning
of the war, leading to a greater number of referrals for cognitive-communication assessments.
The most common physical symptoms reported by service members returning from
combat include headache, nausea, vomiting, fatigue, insomnia and other sleep disturbances,
sensitivity to lights and noise, blurred vision, dizziness, and poor balance (Alexander, 1995;
DVBIC, 2006). In addition, patients with mTBI complain of cognitive-communication problems
including attentional impairments, reduced processing speed, memory dysfunction, impaired
executive functioning, and language difficulties (Binder, 1997; French & Parkinson, 2008).
Following mTBI, the physical and cognitive symptoms are transient, with most people
recovering within weeks to months following their injury (Evans, 1992). Only 10-15% of mTBI
patients have disabling symptoms that last years after injury (Kushner, 1998; Willer & Leddy,
2006). For these individuals, the cognitive sequelae can lead to persistent post-concussive
syndrome (PCS), defined as the continuation of at least three of the following symptoms:
headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and
lowered tolerance for noise and light (Legome & Wu, 2006). A brief period of dazed
consciousness immediately after a concussive event can lead to significant limitations on one’s
ability to function in competitive work and social contexts (Alexander, 1995). Statistics quoted
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in the literature on PCS are based primarily on mTBI resulting from sports-related injuries,
falls, assaults, and motor vehicle accidents. The biomechanics of blast injury are known to
differ and, therefore, the long-term impact on physical and cognitive-communication
functioning remains unclear.
SLPs have traditionally played a major role in the evaluation and management of
cognitive-communication disorders following head injury (ASHA, 2007). Consistent with the
1998 NIH Consensus Statement on Rehabilitation of Persons with Traumatic Brain Injury,
SLPs work to enhance the ability of individuals with TBI to function in all aspects of family and
community life by utilizing restorative and compensatory treatment approaches to acute and
post-acute rehabilitation with the patient and caregivers. However, there are no standardized
assessment batteries or evaluation protocols for documenting the CCD following mTBI. SLPs
are challenged with defining and administering consistent and comprehensive evaluations of
service members returning from combat with blast-related TBI symptoms in an effort to
understand the nature of the impairments and to provide the most effective interventions.
Assessment Measures
According to preferred practice guidelines of the American Speech-Language-Hearing
Association (ASHA, 2004) the purpose of the assessment of cognitive-communication skills is to
identify and describe underlying strengths and weaknesses related to cognitive, executive
function/self-regulatory, and linguistic factors, including social skills, as well as the effects of
cognitive-communication impairments on the individual's capacity and performance in
everyday communication contexts or his or her participation. Outcomes of the assessment may
include diagnosis of a cognitive-communication disorder, clinical description of the
characteristics of a cognitive-communication disorder, prognosis, recommendations for
intervention and support, and referral for other assessments or services.
Historically, SLPs utilized a variety of measures for assessing patients with mTBI. In a
survey study of SLPs who were assessing mTBI, Duff, Procter, and Haley (2002) noted that the
most frequently employed assessment instruments were the Ross Information Processing
Assessment (RIPA; Ross-Swain, 1996), the Boston Diagnostic Aphasia Exam (BDAE;
Goodglass, Kaplan, & Barresi, 2000), the Boston Naming Test (BNT; Kaplan, Goodglass, &
Weintraub, 2000), and the Scales of Traumatic Brain Injury (SCATBI; Adamovich & Henderson,
1992). The authors concluded that two of the most popular instruments used for assessing
cognitive-communication function were designed to assess aphasia, not traumatic brain injury.
Furthermore, the authors state, “These instruments do not assess the cognitive deficits that
are the hallmark of TBI, and they are particularly insensitive to subtle deficits found in
individuals with mTBI” (p. 782). There have been other criticisms of existing test batteries,
including the absence of a comprehensive assessment that examines all major areas of
cognitive-communicative functioning and the lack of a validated assessment tool within a
naturalistic environment.
To address some of the issues described above, the Academy of Neurologic
Communication Disorders and Sciences (ANCDS) embarked on a 5-year project to develop a
range of evidence-based practice guidelines for populations of patients with specific
neurological impairment, including cognitive-communication disorders after traumatic brain
injury (Frattali et al., 2003). In attempting to address the question of what tests can or should
be used for assessment of communication ability in persons with TBI, the committee completed
a review of 127 standardized assessments that were recommended by SLPs, test publishers, or
distributers for use with TBI patients (Turkstra et al., 2005). Further review was conducted of
only those tests that were explicitly designed for or administered to patients with TBI. Thirty-
one tests for children, adolescents, and adults met this criterion and were then reviewed for
reliability and validity measures established by the Agency for Health Care Policy Research
(AHCPR). Seven tests met these strict criteria (see Appendix).
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In the summary of their review, Turkstra, Coelho, and Ylvisaker (2005) stated, “The
tests recommended by speech-language pathologists were strong in content validity but
relatively weak in construct validity” (p. 219). The authors went on to criticize the “striking
absence of a test developed for the evaluation of communication in individuals with cognitive-
communication disorders, versus tests of basic neuropsychological functions that may be
administered by speech-language pathologists or tests borrowed from other populations, such
as aphasia” (p. 219).
Whelan, Murdoch, and Bellamy (2007) reported a case study that documented
impairment in cognitive-communication skills following mild TBI utilizing a test protocol that
assessed higher order linguistic functioning. Their protocol consisted of the Scales of Cognitive
Ability for Traumatic Brain Injury (SCATBI; Adamovich & Henderson, 1992), the Neurosensory
Centre Comprehensive Examination of Aphasia (NCCEA; Spreen & Benton, 1969), the Boston
Naming Test (BNT) (Kaplan et al., 2000), the Test of Language Competence-E (TLC-E; Wiig &
Secord, 1989), the Word Test (Revised; Huisingh, Barrett, Zachman, Blagden, & Orman, 1990),
the Wiig-Semel Test of Linguistic Concepts (Wiig & Semel, 1974), and an on-line lexical
decision task incorporating real and non-real words (Azuma & Van Orden, 1997). The authors
emphasized the importance of assessing higher-level linguistic skills requiring input from the
frontal lobes, skills that have been associated with severe TBI. They selected these instruments
because they had documented validity and reliability as measures of language functions.
Specific deficits in attention, word retrieval, and executive functions were identified by the
instruments they administered.
Many authors recommend a combination of standardized and non-standardized
assessments to document real world functioning (Turkstra et al., 2005; Coelho et al., 2005;
Milton, 1988; Sohlberg & Mateer, 1989). The inclusion of non-standardized and “informal”
assessments is critical in the TBI assessment process, as the testing conditions themselves
may “compensate for the cognitive communication problems traumatically head-injured
patients have in society” (Milton, 1988, p. 5). According to Turkstra and McCarty (2006),
communication competence, that is, the use of language within social contexts, is best
assessed outside of the clinic in conversational interactions rather than in structured clinical
interviews.
NMCSD Protocol
At the Naval Medical Center San Diego (NMCSD), patients sustaining a combat injury
are automatically assigned to the care of the comprehensive and complex combat casualty care
(C-5) team. The C-5 multidisciplinary team consists of physicians, nurses, therapists, case
managers, military, and civilian personnel involved in supporting the medical and military
transition needs of combat-related wounded and ill service members. The Speech-Language
Pathology Division may receive referrals for cognitive-communication evaluations from any
member of the C5 team. The majority of the consultations are requested by otolaryngology,
primary care, case management, neurology, and neuropsychology.
Between September 2006 and October 2008, more than 200 combat-injured service
members were referred for speech pathology evaluations. The typical combat-injured patient
seen in the clinic was an enlisted male serving in the infantry, between the ages of 22 and 25,
with a high school diploma or equivalent and a history of blast exposure resulting in a brief
period of altered or loss of consciousness as reported by the individual. Detailed documentation
of the combat injury, including duration of loss or altered consciousness and period of post-
traumatic amnesia, was scant for the majority of the patients. Most patients completed
neuropsychological testing prior to being referred to speech-language pathology. Many patients
had multiple co-morbidities including PTSD or other psychological health concerns, such as
depression, anxiety, or adjustment disorder.
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To begin addressing the challenge of objectively capturing the presence of cognitive-
communication deficits following blast exposures, the NMCSD SLP staff completed a
comprehensive review of the literature on assessment of cognitive-communication disorders. A
protocol was developed with the goal of answering two questions:
1. What are the functional symptoms of CCD being described by service members?
2. Which evaluation measures are best for identifying CCD of mTBI sustained in
combat?
The protocol consisted of a subjective rating scale, selected portions of various
standardized test batteries, and informal measures. Completing the individual evaluations
required at least two 1-hour visits and sometimes three. The protocol was modified over time to
include informal measures of conversational skills collected during a cognitive-communication
group. A retrospective study of the evaluations of the service members referred during this time
period found 117 completed evaluations for patients exposed to blasts. Cases excluded from
this study included those who sustained brain injury from motor vehicle accidents or those
found to have incomplete data. Some patients failed to return to the clinic to complete testing.
To better understand the nature of the cognitive-communication concerns of service
members returning from combat, the Speech Language Cognitive Rating Scale (SLCRS) was
developed and given to patients to complete. This rating scale was adapted from a
questionnaire developed by Sohlberg and Mateer (2001) for use with the Attention Process
Training (APT) program. The NMCSD questionnaire included 14 questions that service
members rated on a 1 to 4 scale ranging from “not a problem” to “always a problem.
Selected subtests from the following evaluation instruments were used to evaluate
cognitive-communication abilities: Woodcock-Johnson III (WJ-III; Woodcock, McGrew, &
Mather, 2001), the Functional Assessment of Verbal Reasoning and Executive Strategies
(FAVRES; MacDonald, 2003), and the Attention Process Training Test (Sohlberg & Mateer,
2001). The WJ-III consists of two distinct, co-normed batteries: the WJ-III Tests of Cognitive
Abilities (WJ-III COG) and the WJ-III Tests of Achievement (WJ-III ACH). Finally, informal
measures of conversation were collected in a group context.
The WJ-III was selected because it provides individual subtest and cluster standard
scores and percentiles and is normed on over 8,000 subjects, ages 2 years to geriatrics; thus, it
provides a strong normative reference against which to compare the patient population. In
addition the test is comprehensive in nature, examining both cognitive and linguistic skills
across a variety of tasks. Although it has not been normed on patients with brain injury, it has
been used extensively to evaluate the cognitive-communication abilities, scholastic aptitude,
oral language, and achievement across the age-span to predict academic and vocational
success. The test has been shown to be sensitive for identifying learning disabilities.
The FAVRES was included because it was designed to evaluate subtle cognitive-
communication difficulties “which may not be apparent on typical standardized tasks”
(MacDonald, 2005, p. 1). Unfortunately, this instrument was not included in the test protocol
until early 2008, when it became available to the NMCSD SLP staff.
The Attention Process Test (APT) was included in the protocol as a baseline measure of
attentional processes frequently impaired following mTBI. Rehabilitation of attentional deficits
using the APT program is one of the few evidence-based treatments for persons with mTBI
(Rohling, Faust, Beverly, & Demakis, 2009). The APT test provides an assessment of the five
theoretical domains of attention (focused, sustained, selective, divided, and alternating) under
different conditions. The test’s authors do not advocate for using the APT test as an isolated
assessment measure, but rather as a baseline for defining where to begin treating attention
using the APT program. It provides the scope of attention performance of mTBI individuals in a
small sample.
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Informal evaluation of social language skills was completed during weekly cognitive-
communication groups. Pragmatic skills such as topic maintenance, coherence, topic initiation,
turn-taking, and paralinguistic functions were tracked and described on-line for later review
and interpretation.
Assessment Findings
Evaluation results reported here represent only preliminary impressions, because the
sample size is small (N=117). The test protocol continues to be used in the clinic, and final data
analysis will not be completed until the sample size is much larger. On the SLCRS self
assessment, patients rated irritability as the foremost concern, followed by difficulty with word
finding and recalling names. Performance results from the WJ-III revealed that, while the
majority of the service members scored within normal limits on the clusters and subtests
focused on language knowledge, measures of cognitive efficiency were consistently below the
mean when compared to normals. The group mean across the WJ-III subtests fell within
normal limits with a standard score of 92, but was less than the normative mean of 100. More
than 25% of patients scored below one standard deviation on 8 of 11 subtests and clusters.
Fifty percent of the patients scored below one standard deviation on measures of cognitive
efficiency, visual matching, and retrieval fluency. Few patients had difficulties on subtests of
auditory working memory and verbal tasks. Preliminary impressions of APT performance
measures suggest that patients have greater difficulties on the selective and divided attention
subtests when compared to normals. On the FAVRES, patients demonstrated accurate task
performance and verbal reasoning skills; however, their performance reflected slow speed of
information processing.
Anecdotal review of pragmatic data suggests slow response time and difficulties with
expansion, elaboration, and topic maintenance. Disturbed speech prosody—with repetitions,
substitutions of initial words, and grammatical rephrasing of statements—was evident in some
subjects, particularly in a group setting.
Discussion
It was interesting to learn that patients rated irritability as their major concern; yet,
they verbally complained most often of memory difficulties. Their awareness of their decreased
emotional stability may reflect the challenges they face in re-integrating into their families and
community; learning to cope with PTSD and depression; or their frustration with changes in
their cognitive-communication abilities.
As a group, the patients scored within the normal range on the WJ-III, with an overall
mean only slightly below the test mean for the normative population. On the cognitive subtests,
the patients scored below the mean by greater than one standard deviation with lower
performances on tests of cognitive efficiency, visual matching, and retrieval fluency.
Additionally, test data showed low performance scores on measures of attention and
information processing, as well as difficulties with pragmatic communication and speech
production. The speech pattern was characteristic of a motor speech or fluency disorder, but
was inconsistent with the typical presentation of apraxia, dysarthria, or stuttering. The
patients’ dysprosodic repetitions, substitutions, and rephrasing appeared to represent self-
corrections taking place following their verbal output. The corrections may reflect the use of
compensatory strategies for extending processing time and rehearsing auditorily their verbal
productions. Collectively, these findings provide evidence that the evaluation protocol was
sensitive at measuring mild cognitive-communication impairments in the patient group.
The goal of the SLP's evaluation is to document the presence and severity of CCD in
service members returning from combat. It is not to diagnose mTBI; this is the role of the
neuropsychologist, neurologist, and physiatrist. However, clinicians need to be cognizant that,
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following deployment, service members may present with a host of risk factors for CCD. It is
well documented that cognitive impairments may co-exist with PTSD, depression, sleep
disorders, pain, and medication effects (Danckwerts & Leathem, 2003; Gallassi, Di Sarro,
Morreale, & Amore, 2006; Weiner, Freedheim, Schinka, & Velicer, 2003; Trudel, 2007; Terrio et
al., 2009). The extent to which these co-morbidities contribute to test performance remains
uncertain. Answering this question requires a coordinated and comprehensive interdisciplinary
approach to the evaluation of CCD in mTBI. Speech Pathology, along with Neuropsychology,
Neurology, Psychiatry, and other mental health disciplines, is an essential team member in the
evaluation process.
Future Directions
We continue to evaluate methods for improving our current test battery. For example,
we want to implement a standardized pragmatic protocol and assess functional performance in
natural communication contexts. Examples of instruments that may be considered for
addressing these domains include the Profile of Pragmatic Impairment in Communication
(PPIC; Linscott, Knight, & Godfrey, 2003), the Social Communication Skills Questionnaire-
Adapted (SCSQ-A; McGann, Werven, & Douglas, 1997), the Profile of Functional Impairment in
Communication (PFIC; Linscott, Knight, & Godfrey, 1996), and the Behavior Rating Inventory
of Executive Function-Adult version (BRIEF-A; Roth, Isquith, & Gioia, 2005). Once we have
established a full complement of standardized and functional evaluation instruments, we plan
to conduct further analysis to examine for the effects of co-morbidities on test performance.
The impact of co-morbidities can potentially drive decisions regarding when to evaluate
patients, which measures to use, and how to interpret the findings relative to treatment
planning.
Summary
The Global War on Terror has led to a significant increase in the diagnosis of mTBI in a
large percentage of returning soldiers (Hoge, 2008). As a result, medical professionals,
including SLPs all over the country, are being called upon to evaluate and treat CCD sustained
in combat. Little is known about the CCD in this population, and accurate assessment is
complex, requiring consideration of physical and psychological factors. Speech-language
pathologists play a key role in early assessment, education, counseling, and direct intervention
of persisting cognitive-communication impairments (ASHA, 2005b; Roth, 2008). An
interdisciplinary rehabilitation model is essential to providing effective evaluation. There is a
need for clinical research to expand our understanding of the impact of blast injuries on
cognitive-communication processes, to define prognosis for recovery, and to design evidence-
based intervention programs (Roth, 2008).
Christine Parrish is a staff speech-language pathologist at Naval Medical Center San
Diego. She has worked in the rehabilitation field for 15 years, specializing in evaluation and
treatment of cognitive-communication disorders following traumatic brain injury (TBI). Ms.
Parrish has worked with TBI patients at all acuity levels, including inpatient and outpatient
rehabilitation and day treatment. She has participated in the evaluation and treatment of
active duty service members since the onset of the Global War on Terror (GWOT) and is
involved in ongoing research with this population.
Carole R. Roth is chief of Speech Pathology at the Navy Medical Center San Diego and
assistant professor in the Department of Speech-Language and Hearing Sciences at San Diego
State University. Dr. Roth has many years of clinical experience working with acquired brain
injuries. She was former president of the Boulder Chapter of the Colorado Head Injury
Association and established a camp in the Rocky Mountains for survivors of traumatic brain
54
injury. Dr. Roth has authored journal articles and has spoken nationally and internationally in
the areas of motor speech disorders and rehabilitation following TBI.
Brooke Roberts is a staff speech-language pathologist at Naval Medical Center San
Diego (NMCSD). She earned her master’s degree in Communication Disorders from the
University of Virginia. She has been a member of the Comprehensive Combat and Complex
Casualty Care (C-5) program, the NMCSD multidisciplinary rehabilitation team, since
November 2007. Her prior brain injury experience includes serving veterans in the VA system
in Florida.
Gail Davie is formerly a staff speech-language pathologist at Naval Medical Center. She
earned her undergraduate and graduate degrees from Ohio University. She was a member of
the Comprehensive Combat and Complex Casualty Care (C-5) program, the NMCSD
multidisciplinary rehabilitation team. Her prior experience was working with adults with
neurogenic communication problems at MD Anderson Cancer Center.
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Appendix. Reliable and Valid Tests for TBI (Turkstra, Coelho, &
Ylvisaker, 2005)
American Speech-Language-Hearing Association Functional Assessment of
Communication Skills in Adults (ASHA FACS)
Behavior Rating Inventory of Executive Function (BRIEF)
Communication Activities of Daily Living (CADL-2)
Functional Independence Measure (FIM; Uniform Data System for Medical
Rehabilitation)
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
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Test of Language Competence-Extended (TLE-C)
Western Aphasia Battery (WAB)
... 773). In military medicine, Parrish et al. (2009) stated, "Evaluation instruments historically used are insensitive to the subtle deficits found in individuals with mTBI" (p. 47). ...
... Woodcock-Johnson (WJ) tests are cited as appropriate tests for SLPs to consider in mTBI (Duff & Stuck, 2015;Hardin & Kelly, 2019;Krug & Turkstra, 2015;Parrish et al., 2009), and may be one option for improved assessment by SLPs in SRC. WJ subtests were designed to address known impairments in mTBI, have high-quality psychometric properties, are listed in the TBI Common Data Elements Set (National Institute of Neurological Disorders and Stroke, 2013), and can be completed in a relatively short durations in order to limit fatigue postinjury. ...
... The WJ has been used frequently in mTBI for pediatrics, SRC, mixed-mechanism injuries (such as falls and motor vehicle accidents), and military medicine (e.g., Beers et al., 1994;Chapman et al., 1999;Fay et al., 1993;Gans & Kurtzer, 2017;Gidley Larson et al., 2015;Kegel & Collins, 2012;Krivitzky et al., 2011;Ledbetter et al., 2017;Levin et al., 2008;Max et al., 2013;Parrish et al., 2009;Saunders et al., 2015;Segalowitz et al., 2001;Tupper, 1990). There has been significant variability within the literature of subtests and cluster scores utilized, as researchers have selected subtests based on individual subtest constructs and study design needs. ...
Article
Purpose The purpose of this study was to evaluate changes in cognitive-communication performance using Woodcock–Johnson IV Tests (WJIV) from pre-injury baseline to post sport-related concussion. It was hypothesized that individual subtest performances would decrease postinjury in symptomatic individuals. Method This prospective longitudinal observational nested cohort study of collegiate athletes assessed cognitive-communicative performance at preseason baseline and postinjury. Three hundred and forty-two male and female undergraduates at high risk for sport-related concussion participated in preseason assessments, and 18 individuals met criteria post injury. WJIV subtest domains included Word Finding, Speeded Reading Comprehension, Auditory Comprehension, Verbal Working Memory, Story Retell, and Visual Processing (letter and number). The power calculation was not met, and therefore data were conservatively analyzed with descriptive statistics and a planned subgroup analysis based on symptomatology. Results Individual changes from baseline to postinjury were evaluated using differences in standard score performance. For symptomatic individuals, mean negative decreases in performance were found for Retrieval Fluency, Sentence Reading Fluency, Pattern Matchings, and all cluster scores postinjury. Individual performance declines also included decreases in story retell, verbal working memory, and visual processing. Conclusions This study identified within-subject WJIV performance decline in communication domains post sport-related concussion and reinforces that cognitive-communication dysfunction should be considered in mild traumatic brain injury. Key cognitive-communication areas included speeded naming, reading, and verbal memory, though oral comprehension was not sensitive to change. Future clinical research across diverse populations is needed to expand these preliminary findings.
... In one study of the incidence of cognitive complaints following concussion, 42%-57% of young adults and adolescents reported these problems (Eisenberg et al., 2014). Communication problems following concussion are thought to be related to cognitive rather than language changes (Cornis-Pop et al., 2012;Parrish et al., 2009;Sohlberg & Mateer, 2001), yet not all cognitive problems may result in communication problems. Therefore, communication complaints may be expected to 1. ...
... Group conversation is often perceived as being difficult because of competing auditory streams and rapid changes in speakers and topics, along with difficulty in quickly recognizing and reacting to conversational pauses and cues to speak versus wait for another speaker (Krause et al., 2014;Vander Werff & Rieger, 2019). Similarly, needing extra time to think specifically points to difficulty with speeded processing, which is known to be impacted by mTBI and to impact communication and linguistic processing (Hardin, 2021;Norman et al., 2019;Parrish et al., 2009;Stockbridge et al., 2018). This item may be related to both needing extra time to understand messages or to formulating responses, whereas needing the conversation partner to repeat points more directly to auditory comprehension and perhaps working memory to interpret meaning across clauses or integrate incoming streams of information. ...
Article
Purpose Speech-language pathologists are increasingly being recognized as key members of concussion management teams. This study investigates whether self-report of communication problems postconcussion may be useful in identifying clients who could benefit from speech-language pathology services. Method Participants included 41 adolescents and adults from an outpatient specialty concussion clinic. All completed the La Trobe Communication Questionnaire (LCQ) at admission, and 23 repeated this measure at discharge. Participants were prospectively enrolled, with chart reviews providing demographic, injury, and medical factors. The analysis considered (a) communication complaints and resolution over time, including comparison to two previously published LCQ studies of typical adults and adults with and without traumatic brain injury (TBI); (b) the relationship between communication complaints, participant factors, and common concussion assessments; and (c) factors related to speech-language pathology service referral for rehabilitation. Results At first visit, 12 of 41 participants (29%) reported communication problems, although 19 (46%) reported difficulty with greater than half of LCQ items. At a group level, compared to published reference data of both people with chronic mixed severity TBI and controls, participants in this study reported more problems at first visit with communication overall, as well as greater difficulty with the LCQ Initiation/Conversation Flow subscale. Partner Sensitivity subscale scores at first visit were also greater than published control data. LCQ subscale scores of Initiation/Conversation Flow and Partner Sensitivity decreased from first visit to last visit, demonstrating resolution over time. Only concussion symptom scales and not demographic, injury, or cognitive screenings were related to LCQ scores. The same two LCQ subscales, Initiation/Conversation Flow and Partner Sensitivity, predicted referral for speech-language pathology services, along with symptom scales and being injured due to motor vehicle crash. Discussion A subset of people recovering from concussion report experiencing communication problems. Reporting of particular communication problems was related to referral for speech-language pathology rehabilitation services and may be useful in directing care after concussion.
... Because of the well-established influence of cognition on communication performance as well as the risk of neurogenic fluency disorders in the mTBI population (Mattingly, 2015;Norman et al., 2013Norman et al., , 2018Parrish et al., 2009), one measure of potential sensitivity to mTBI-related communication deficits was hypothesized to be the measure of a disfluency, which has been shown to be sensitive to moderate to severe TBI populations because of the association between sentence planning deficits, attentional control, and working memory deficits (Peach, 2013). In other cognitively impaired populations, such as adults with mild cognitive impairment, the dysfluency index has also been found to be a sensitive cognitive-linguistic marker (Mueller et al., 2018). ...
Article
Introduction Adults with mild traumatic brain injury (mTBI) are at risk for communication disorders, yet studies exploring cognitive-communication performance are currently lacking. Aims This aim of this study was to characterize discourse-level performance by adults with mTBI on a standardized elicitation task and compare it to (a) healthy adults, (b) adults with orthopedic injuries (OIs), and (c) adults with moderate to severe TBI. Method This study used a cross-sectional design. The participants included mTBI and OI groups recruited prospectively from an emergency medicine department. Moderate to severe TBI and healthy data were acquired from TalkBank. One-way analyses of variance were used to compare mean linguistic scores. Results Seventy participants across all groups were recruited. Groups did not differ on demographic variables. The study found significant differences in both content and productivity measures among the groups. Variables did not appear sensitive to differentiate between mTBI and OI groups. Discussion Cognitive and language performance of adults with mTBI is a pressing clinical issue. Studies exploring language with carefully selected control groups can influence the development of sensitive measures to identify individuals with cognitive-communication deficits.
... in the sample were diagnosed with cognitive-communication disorder. This finding is not surprising, as this type of disorder, defined "as any difficulty with communication as a result of cognitive impairment" (American Speech-Language-Hearing Association, 2005), is common after TBI and has been well documented in the moderate-to-severe TBI civilian literature over several decades (Coelho et al., 1996(Coelho et al., , 2005Krug & Turkstra, 2015;MacDonald, 2016;MacDonald & Johnson, 2005;Parrish et al., 2009). The cognitivecommunication diagnosis code was not included in Norman et al. (2013), the initial study of communication disorders in this population, as that study strictly focused on more focal expressive communication disorders. ...
Article
Purpose To describe the prevalence of communication disorders in a cohort of 84,377 deployed post-9/11 veterans stratified by blast traumatic brain injury (TBI) exposure. Secondary aim was to evaluate the association between postconcussion symptoms, such as posttraumatic stress disorder, depression, anxiety, insomnia, pain, headache, substance use disorder, and auditory problems, among veterans with and without a communication disorder diagnosis. Method This is a retrospective study of the prevalence of aphasia, apraxia of speech and dysarthria, cognitive-communication disorder, fluency, and voice disorders among veterans, stratified by TBI severity and blast status. Data were obtained from the national Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn roster file provided by the Department of Veterans Affairs Office of Public Health and the Veterans Affairs' TBI screening and subsequent comprehensive TBI evaluation. Results Cognitive-communication disorder was the most prevalent diagnosis, comprising 57.1% of all communication disorder diagnoses, followed by voice disorder (19%) and aphasia (16%). Increased age was significantly associated with higher rates of aphasia, apraxia of speech/dysarthria, and voice disorder. Conclusions The current study shows that, while the overall total number of communication disorder diagnoses was higher in the blast groups than in the nonblast groups, TBI severity was a more significant risk factor for a diagnosis, with veterans in the more severe groups at a higher risk of being diagnosed with a communication disorder when compared to those with mild TBI and no blast exposure. In order to better inform rehabilitation and clinical management of communication conditions, it is critical to examine the influence of blast and postconcussive symptoms in post-9/11 veterans.
... For instance, the FAVRES was particularly useful in identifying impairments in one person in the epilepsy group who fell greater than 1 SD below the mean in terms of time taken, accuracy, reasoning, and rationale scores. MacDonald and Johnson (2005) and Parrish et al. (2009) also found that the FAVRES demonstrates good clinical sensitivity and acceptable interrater reliability in terms of detecting cognitive-communication deficits subsequent to mild brain injury. Additionally, spoken discourse analysis is considered to be another sensitive and ecologically valid measure to identify the complex language deficits of individuals with mild acquired brain damage, which are often missed by standardized language tests (Coelho et al., 2005). ...
Article
Purpose Cognition and language difficulties are frequently reported in both children and adults with epilepsy. The majority of the existing research has focused on pediatric epilepsy, documenting impairments in learning, academics, and social–emotional functioning. In comparison, language deficits in younger and older adults with epilepsy have received less empirical attention. Given recently identified limitations in the extant literature regarding assessing epilepsy-related language problems in adults ( Dutta et al., 2018 ), the current exploratory study described in this research note investigated the cognitive–linguistic abilities of adults with focal or generalized types of epilepsy. Method Twelve participants with epilepsy and 11 age- and education-matched healthy controls completed a cognitive–linguistic test battery. Event-related potential (ERP) procedures were also employed to assess the integrity of neural activity supporting psycholinguistic processing in both groups using a lexical decision task. Results No significant performance differences between epilepsy and healthy control groups were noted on basic language tasks; however, group differences were evident on the more complex language measures, including spoken discourse. Even though both groups performed the lexical decision task similarly in terms of accuracy, individuals with epilepsy demonstrated longer reaction times and some atypical ERP characteristics compared to controls. Conclusion The cognitive–linguistic assessment and ERP findings suggested that, compared to neurotypical adults, individuals with epilepsy demonstrate slower processing times and greater difficulty with high-level language and spoken discourse production, despite performing within typical limits on basic language tests. Preliminary results from this research are significant in providing new knowledge about language functioning in adults with epilepsy.
... Shortcomings in speech-language pathologists (SLPs) assessment tools have contributed to the gap in knowledge about cognitive-linguistic performance problems after mTBI. Often, patients report problems in their everyday lives and are referred to SLPs for treatment and it has been a challenge to document these problems using standardized tests (26,27). Although there have been some advances made in evaluating cognitive-linguistic performance skills for moderate to severe TBI using measures such as the Functional Assessment of Verbal Reasoning and Executive Strategies Test (28) and discourse assessment (29), overall standardized language tests lack sensitivity and specificity for detecting the mild deficits that are characteristic of mTBI (30,31). ...
Article
Full-text available
Objective: The purpose of this study was to characterize cognitive-linguistic performance in adults with mild traumatic brain injury (mTBI) to advance assessment and treatment practices. We hypothesized that individuals with mTBI would demonstrate longer reaction times (RTs) and greater error rates when compared to an orthopedic injury (OI) group on a category-naming task. Method: Participants were age and education-matched adults with mTBI (n = 20; 12 females) and adults with OI (n = 21; 5 females) who were discharged to home after an Emergency Department visit. Our primary task was a category-naming task shown to be sensitive to language deficits after mTBI. The task was adapted and administered under speeded and unspeeded conditions. Results: There was a significant main effect of condition on RT (speeded faster than unspeeded) and accuracy (more errors in the speeded condition). There was a marginally significant effect of group on errors, with more errors in the mTBI group than the OI group. Naming RT and accuracy in both conditions were moderately correlated with injury variables and symptom burden. Conclusions: Our data showed a marginal effect of group on accuracy of performance. Correlations found between naming and neurobehavioural symptoms, including sleep quality, suggest that the latter should be considered in future research.
... 39,40 Adults with persistent symptoms from motor vehicle accidents had significantly reduced production of words in both semantic and phonological speeded naming tasks 18 and decreased categorical fluency has also been found in those with injuries resulting from exposure to blast. 41 In the SLP evaluation, word finding is assessed under speeded conditions, often with both generative and confrontational conditions. While categorical naming is a standard task (foods, names, and animals), phonological naming, such as the FAS test, where individuals name as many words beginning with a targeted letter in one minute, is also utilized. ...
Article
The Marcus Institute for Brain Health (MIBH) provides interdisciplinary care for adults struggling with persistent effects of mild traumatic brain injury and accompanying changes in behavioral health, with specific emphases on Veterans and retired elite athletes. The cognitive, physical, and behavioral symptoms associated with mild traumatic brain injury are interrelated, with neurobiopsychosocial modeling encompassing the factors related to recovery from a traumatic brain injury. The diffuse impacts of chronic concussive injuries require multiple clinical providers to address the breadth of symptoms, facilitating both interdisciplinary and transdisciplinary care models. By implementing integrated practice units, patients receive advanced medical care, imaging, speech-language pathology, physical therapy, behavioral health, neuropsychology, and clinical pharmacy for a cohesive diagnostic and intervention plan. Nationally, speech-language pathologists report challenges with best-practice options for concussion, particularly in the domain of assessment practices. At the MIBH, speech-language pathologists begin their assessment with a structured clinical interview that focuses on patients' needs and concerns. Evaluation modalities focus on hearing, communication, and functional cognition to guide therapeutic treatment planning. The intensive outpatient care program at MIBH incorporates both individual sessions targeting patient-centered goals and group care, where speech-language pathologists work transdisciplinarily to generalize care from all disciplines out into the community. Care practices for concussive injuries continue to evolve rapidly; speech-language pathology at the MIBH offers one such vision for excellence in clinical care.
Article
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Introduction Especially in the chronic phase, individuals with traumatic brain injury (TBI) (IwTBI) may still have impairments at the discourse level, even if these remain undetected by conventional aphasia tests. As a consequence, IwTBI may be impaired in conversational behavior and disadvantaged in their socio-communicative participation. Even though handling discourse is thought to be a basic requirement for participation and quality of life, only a handful of test procedures assessing discourse disorders have been developed so far. The MAKRO Screening is a recently developed screening tool designed to assess discourse impairments. The test construction is based on psycholinguistic frameworks and the concept of macro-rules , which refer to cognitive functions responsible for organizing and reducing complex information (e.g., propositional content) in discourse. Aim The aim of our study was to investigate discourse processing in IwTBI in different tasks and to assess problems in communicative participation in the post-acute and chronic phase. In this context, we also aimed to analyze the influence of the severity of the initial impairment and the verbal executive abilities on the discourse performance. Additionally, the impact of macrolinguistic discourse impairments and verbal fluency on perceived communicative participation was targeted in our analysis. Methods Data from 23 IwTBI (moderate to severe) and 23 healthy control subjects have been analyzed. They completed two subtests of the MAKRO screening: Text production and Inferences . Discourse performance was examined in relation to measures of semantic fluency and verbal task-switching. Socio-communicative problems were evaluated with the German version of the La Trobe Communication Questionnaire (LCQ). Results IwTBI showed lower test results than the control group in the two subtests of the MAKRO-Screening. Difficulties in picture-based narrative text production also indicated greater perceived difficulties in communicative participation (LCQ). We also found that the subject’s performance on the MAKRO-Screening subtests can partly be explained by underlying dysexecutive symptoms (in terms of verbal fluency and verbal task switching) and the severity of their injury. The preliminary results of our study show that cognitive-linguistic symptoms in IwTBI are also evident in the chronic phase. These can be detected with procedures referring to the discourse level, such as the MAKRO-Screening. The assessment of discourse performance should be an integral part in the rehabilitation of IwTBI in order to detect cognitive-linguistic communication disorders and to evaluate their impact on socio-communicative participation.
Article
Introduction Individuals who sustain a mild traumatic brain injury (mTBI) can suffer from executive function, working memory, and attention deficits, which can impact functional task performance, including reading comprehension. Individuals with mTBI commonly report reading difficulties, but such difficulties have been historically difficult to capture using behavioral measures. The current study examined reading performance in those with and without mTBI using eye-tracking measures, which may be more sensitive to reading impairment in mTBI. Method/Results In Experiment 1, 26 participants with a history of mTBI and 26 healthy control participants completed working memory (WM) and reading comprehension tasks. We found no differences in behavioral measures but found that spontaneous eye-blinking frequency was lower during the reading task in the mTBI group. In Experiment 2, we explored the impact of auditory distraction (e.g., multi-talker babble) on reading and memory performance. Twenty-three new participants with a history of mTBI and 26 healthy control participants completed a short-term memory (STM) task, a WM task, and a reading comprehension task under two distraction conditions. As in Experiment 1, we found no differences on behavioral measures, but observed significant differences on spontaneous eye-blinking frequency between those with and without mTBI. Group differences in distraction effects were also observed and performance on the WM task predicted reading comprehension performance. Conclusions The lack of differences on behavioral measures between groups, but lower frequencies of spontaneous eye blinking in the mTBI group suggests that while these individuals successfully completed the reading comprehension task, they may require more cognitive resources to do so.
Article
Primary Objective. The objective of this study was to investigate the factors that might have a negative influence on auditory processing and higher-level language processing in the US veterans of the recent foreign wars (Iraq and Afghanistan). Research Design. Exploratory, cross-sectional, correlational, prospective, cohort-design. Methods and Procedures. The experimental group consisted of 12 US veterans of war (10 males and 2 females) with blast exposure. The control group consisted of six US veterans (5 males and 1 female) without the history of blast exposure. Both groups were matched in mean age. Both groups were tested on Boston Assessment of Traumatic Brain Injury, Consonant Trigrams Test, Symbol Digit Modality Test, Trail Making Test, SCAN-3, CELF-5-Metalinguistics, CASL, and an unpublished test on the processing of sentence prosody. Main Outcomes and Results. Significant group differences in attention, and time-compressed sentence processing were found. For those veterans (in the experimental group) who were not wearing their helmets at the time of blast, additional significant differences were noted with inferencing and auditory figure-ground tasks. Conclusions: Findings support the importance of including speech/language pathologists in all stages of recovery for veterans post-blast exposure.
Article
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The development of comprehension of 50 sentences expressing comparative, passive, temporal, spatial, and familial relationships was evaluated in 210 grade school children. Significant increases in correct responses occurred during the first five grades but not between Grades 5 and 8. The periods during which significant increases occurred differed for sentence categories. In the early grades comparative relationships were easiest followed by passive, temporal, spatial, and familial relationships. The findings suggest that spatial relationships are established earlier in a developmental sequence than temporal relationships. In Grades 1 and 2 WISC Full Scale IQ and comprehension of logico-grammatical sentences correlated significantly.
Article
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This article is one of a series of publications by the Academy of Neurologic Communication Disorders and Sciences (ANCDS) working groups on evidence-based clinical practice (EBP) in neurologic communication disorders. The EPB project was initiated in 1997, when ANCDS established committees of experts to develop EBP guidelines for the following areas: dysarthria, aphasia, dementia, apraxia, and cognitive-communication disorders associated with traumatic brain injury (TBI). The scope and mission of the EBP project are described in detail in previous publications (Golper et al., 2001; Kennedy et al., 2002; Sohlberg et al., 2003). This article was generated by the subcommittee on cognitive-communication disorders associated with TBI, and its purpose is to examine the evidence for the use of standardized, norm-referenced tests. Evaluation and assessment using nonstandardized tests and other approaches will be addressed in a separate publication. The full Technical Report is available at www.ancds.org.
Article
The Academy of Neurologic Communication Disorders and Sciences (ANCDS), by way of the mission, purposes, and activities of its Ad Hoc Practice Guidelines Coordinating Committee and respective Writing Committees, has embarked on a 5-year project to develop a range of evidence-based practice guidelines for specific neurologically impaired patient populations (i.e., dysarthria, dementia, acquired apraxia of speech, developmental apraxia of speech, aphasia, cognitive-communication disorders after traumatic brain injury, and cognitive and communication disorders after right-hemisphere brain damage). The project embraces a philosophy that quality of care is best supported by scientific evidence of treatment efficacy. This article, which details and updates the proceedings from the Committee's presentation at the ANCDS annual educational and scientific meeting in 2002 in Atlanta, Georgia, summarizes the progress to date by the various Writing Committees responsible for developing these evidence-based practice guidelines.
Article
Objective To provide biomedical researchers and clinicians with information regarding and recommendations for effective rehabilitation measures for persons who have experienced a traumatic brain injury (TBI).Participants A nonfederal, nonadvocate, 16-member panel representing the fields of neuropsychology, neurology, psychiatry, behavioral medicine, family medicine, pediatrics, physical medicine and rehabilitation, speech and hearing, occupational therapy, nursing, epidemiology, biostatistics, and the public. In addition, 31 experts from these same fields presented data to the panel and a conference audience of 883 members of the public. The conference consisted of (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussions that were part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and part of the third. Primary sponsors of the conference were the National Institute of Child Health and Human Development and the National Institutes of Health Office of Medical Applications of Research.Evidence The literature was searched through MEDLINE for articles from January 1988 through August 1998 and an extensive bibliography of 2563 references was provided to the panel and the conference audience. Experts prepared abstracts for their conference presentations with relevant citations from the literature. The panel prepared a compendium of evidence, including a patient contribution and reports from federal agencies. Scientific evidence was given precedence over clinical anecdotal experience.Consensus Process The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented during the open forum (October 26-28, 1998) and in the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the Internet immediately following its release at the conference and was updated with the panel's final revisions.Conclusions Traumatic brain injury results principally from vehicular incidents, falls, acts of violence, and sports injuries and is more than twice as likely to occur in men as in women. The estimated incidence rate is 100 per 100,000 persons, with 52,000 annual deaths. The highest incidence is among persons aged 15 to 24 years and 75 years or older, with a less striking peak in incidence in children aged 5 years or younger. Since TBI may result in lifelong impairment of physical, cognitive, and psychosocial functioning and prevalence is estimated at 2.5 million to 6.5 million individuals, TBI is a disorder of major public health significance. Mild TBI is significantly underdiagnosed and the likely societal burden is therefore even greater. Given the large toll of TBI and absence of a cure, prevention is of paramount importance. However, the focus of this conference was the evaluation of rehabilitative measures for the cognitive and behavioral consequences of TBI. Evidence supports the use of certain cognitive and behavioral rehabilitation strategies for individuals with TBI. This research needs to be replicated in larger, more definitive clinical trials and, thus, funding for research on TBI needs to be increased.
Article
Traumatically head-injured individuals who reach the higher stages of recovery typically exhibit cognitive communication disorders. Patient management requires, among other considerations, a focus on functional communication competency, an ecologic-systematic perspective, and use of compensatory techniques. A case study applies this management process to the vocational rehabilitation of a 35-year-old. (JDD) Language: en