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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
48
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,
53
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)
