Traumatic Brain Injury in Adults

Traumatic brain injury (TBI) is a form of nondegenerative acquired brain injury, resulting from an external physical force to the head (e.g., fall) or other mechanisms of displacement of the brain within the skull (e.g., blast injuries). Consistent with the diagnostic criteria detailed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), TBI is associated with one or more of the following characteristics:

  • Changes in levels of consciousness
  • Memory disturbances
  • The confusion associated with deficits in orientation
  • Neurological signs, such as brain injury observable on neuroimaging, new onset or worsening of seizure disorder, visual field deficits, and hemiparesis

TBI can cause brain damage that is focal (e.g., a gunshot wound) or widespread (e.g., a diffuse axonal injury sustained in a motor vehicle accident). Damage can result from a primary injury or a secondary injury.

TBI Severity

The severity of TBI is based on the extent and nature of the injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and extent of confusion at initial assessment during the acute phase of the injury (APA, 2013; Centers for Disease Control and Prevention [CDC], 2015).

The Department of Defense (DOD) defines the following levels of severity (Defense Health Agency, 2019):

  • Concussion/Mild TBI—loss of consciousness for up to 30 minutes; or confused or disoriented state lasting less than 24 hours; or memory loss lasting less than 24 hours. Excludes penetrating TBI. The results of the computed tomography (CT) scan, if obtained, are normal.
  • Moderate TBI—loss of consciousness for more than 30 minutes, but less than 24 hours; or confused or disoriented state lasting more than 24 hours; or memory loss lasting more than 24 hours but less than 7 days; or meets criteria for concussion/mild TBI but with an abnormal CT. Excludes penetrating TBI. A structural brain imaging study may be normal or abnormal.
  • Severe TBI—loss of consciousness for more than 24 hours; or confused or disoriented state lasting more than 24 hours; or memory loss lasting more than 7 days. Excludes penetrating TBI. A structural brain imaging study may be normal but usually abnormal.
  • Penetrating TBI—open head injury; scalp, skull, and dura mater (outer layer of meninges) are penetrated. Caused by high-velocity projectiles, objects of lower velocity such as knives, or bone fragments from a skull fracture that is driven into the brain.
  • Incidence refers to the number of new cases identified in a specific period.
  • Prevalence refers to the number of individuals who are living with TBI in a given period.

General Statistics

Worldwide, in 2016, there were approximately 27 million new cases of TBI with an age-adjusted incidence rate of 369 per 100,000—representing a 3.6% increase from 1990. In the same year, the prevalence was 55.5 million individuals, representing an 8.4% increase from 1990 (Global Burden of Disease [GBD], 2019). Each year, the number of new cases of TBI in the United States is approximately 2.8 million (CDC, 2015). These incidence rates include approximately 2.5 million TBI-related emergency department visits, 288,000 TBI-related hospitalizations, and 57,000 TBI-related deaths. Whereas age-adjusted rates of TBI-related ED visits increased by 54% over 8 years (2006–2014), hospitalization rates decreased by 8% and death rates decreased by 6% (CDC, 2014).

According to the National Center for Injury Prevention and Control, an estimated cumulative 5.3 million individuals are living with a TBI-related disability in the United States. This represents a prevalence of approximately 2% of the U.S. population (CDC, 2015). Additional data suggest the prevalence of U.S. TBI-related disability after hospitalization to be 3.2 million (Zaloshnja, Miller, Langlois, & Selassie, 2008). Current studies estimate that approximately 775,000 older adults live with long-term disabilities associated with TBI (Zaloshnja et al., 2008).

Incidence and prevalence rates of TBI vary across clinical and epidemiological studies. These variations are often due to differences in participant characteristics (e.g., ages included), diagnostic classification criteria within and across subtypes (e.g., mild TBI vs. severe TBI), and sources of data (e.g., hospital admissions, emergency room visits, general practitioner visits). Moreover, current statistics do not consider individuals who do not seek medical care. Therefore, these estimates may significantly underestimate the incidence and prevalence of TBI.


The TBI prevalence in the general population is 16.7% among males and 8.5% among females. The odds of sustaining a TBI are 2.22 times higher in men than in women (Frost, Farrer, Primosch, & Hedges, 2012). Overall, males account for approximately 59% of all reported TBI-related medical visits in the United States (Faul, Xu, Wald, & Coronado, 2010).


As many as 75% of individuals who experience a TBI are diagnosed with mild TBI. This is likely an underestimate of the problem, as patients with mild TBI—who are often treated outside the hospital setting or are not treated at all—are not included in most estimates. In addition, this number includes only mild TBIs in the civilian population (CDC, 2003). It is believed that factors such as automobile safety, seatbelt use, helmet use, and better overall treatment for severe TBI in prehospital and hospital settings, while unable to prevent TBIs entirely, have mitigated the severity and thus mortality (Thurman et al., 1999).

Signs and symptoms of TBI vary, depending on the site and extent of injury to the brain, premorbid abilities, and functional domains affected (e.g., physical, cognitive, language, and sensory). The effects of TBI can be temporary or permanent, and no two individuals present with the same pattern.

The clinician considers cultural differences that may lead to differences in the presentation of certain cognitive measures (e.g., response time, self-monitoring, executive functioning).

Signs and Symptoms Related to Traumatic Brain Injury


  • Changes in bowel and bladder function
  • Changes in the level of consciousness, ranging from brief loss of consciousness to coma
  • Dizziness
  • Fatigue
  • Headaches
  • Impaired movement, balance, and/or coordination
  • Motor speed and programming deficits (dyspraxia/apraxia)
  • Nausea
  • Pain
  • Reduced muscle strength (paresis/paralysis)
  • Seizures
  • Vomiting


Auditory and Vestibular

  • Auditory dysfunction from injury to the outer ear, middle ear, inner ear, and/or temporal lobe, resulting in


  • Changes in perception of color, shape, size, depth, and distance
  • Changes in visual acuity
  • Blurred vision
  • Double vision (diplopia)
  • Problems with visual convergence and accommodation
  • Sensitivity to light
  • Visual field deficits/visual neglect

Other Sensory–Perceptual Sequelae

  • Gustatory—loss of taste
  • Olfactory—inability to recognize smells
  • Tactile—sensitivity or defensiveness to touch; changes in perception of pain, pressure, and/or temperature



  • Deficits in shifting attention between tasks
  • Difficulty with selective attention
  • Impaired sustained attention (e.g., for task completion)
  • Reduced attention span

Executive Functioning

  • Difficulty with the following:

Information Processing

  • Increased response latencies
  • Reduced processing speed (e.g., of rapid speech and/or complex language), resulting in confusion

Memory and Learning

  • Deficits in short-term memory that negatively affect new learning
  • Deficits in working memory that negatively affect following directions and task completion
  • Difficulty remembering to perform a planned action (prospective memory) such as remembering to take medication
  • Difficulty retrieving information from memory
  • Post-traumatic amnesia is marked by impaired memory of events that happened shortly before the injury (retrograde)


  • Lack of insight for monitoring one’s strengths, weaknesses, functional abilities, problem situations, and so forth
  • Reduced awareness of deficits (anosognosia)

Other Cognitive Deficits

  • Deficits in orientation to self, situation, location, and/or time
  • Impaired spatial cognition can affect the ability to navigate and ambulate


Pragmatic/Social Communication

  • Conversational turns marked by verbosity
  • Difficulty initiating conversation and maintaining topic
  • Difficulty taking turns in conversation
  • Difficulty inhibiting inappropriate language or behavior
  • Impaired ability to use nonverbal communication effectively (e.g., tone of voice, facial expression, body language)
  • Impaired social cognition skills (e.g., regulating emotion; expressing emotion, and perceiving emotion of others; ability to take the perspective of others and to modify language accordingly)
  • Inability to interpret others’ nonverbal communication
  • Tendency to be tangential

Spoken Language

  • Anomia or word retrieval deficits
  • Decreased ability to formulate organized discourse or conversation
  • Difficulty following directions
  • Difficulty formulating fluent speech
  • Difficulty making inferences
  • Difficulty understanding abstract language/concepts
  • Difficulty making inferences
  • Tendency to perseverate in verbal responses
  • Tendency to use tangential speech
  • Use of incoherent or confabulatory speech

Written Language

  • Difficulty comprehending written text, particularly concerning complex syntax and figurative language
  • Difficulty planning, organizing, writing, and editing written products


  • Apraxia of speech (motor programming)
  • Aprosodia/dysphonia, marked by deficits in intonation, pitch, stress, and rate
  • Dysarthria characterized by reduced respiratory support, articulatory imprecision, and/or vowel distortions
  • Hypernasality secondary to paresis or paralysis of velopharyngeal muscles involved in speech


  • Aphonia/dysphonia resulting from intubation, tracheostomy, or use of a mechanical ventilator
  • Laryngeal hyper/hypofunction marked by
  • Neurogenic phonatory abnormalities resulting from injury to sensory or motor innervations to the vocal folds
  • Psychogenic phonatory abnormalities (e.g., related to post-traumatic stress disorder)


  • Swallowing problems secondary to oral and/or pharyngeal sensory disorders and/or motor deficits (e.g., weakness or paralysis of oropharyngeal musculature, oral apraxia)
  • The risk of aspiration while eating is related to the impact of cognitive impairment (e.g., poor memory, reduced insight, limited attention, impulsivity, and agitation; Logemann, 2006; Morgan, Ward, & Murdoch, 2004)


  • Affective changes, including over-emotional or over-reactive effects or flat (i.e., emotionless) effect
  • Agitation and/or combativeness
  • Anxiety disorder
  • Depression
  • Difficulty identifying emotions in others (alexithymia)
  • Emotional lability and mood changes or mood swings
  • Excessive drowsiness and changes in sleep patterns, including difficulty falling or staying asleep (insomnia), excessive sleepiness (hypersomnia)
  • The feeling of disorientation or fogginess
  • Increased state of sensory sensitivity accompanied by an exaggerated response to perceived threats (hypervigilance)
  • Impulsivity
  • Irritability and reduced frustration tolerance
  • Lack of initiation (e.g., for making choices, talking, moving)
  • Stress disorders

Considerations for Bilingual and Multilingual Speakers

Cognitive control deficits have a unique impact on the linguistic abilities of bilingual and multilingual speakers (Ansaldo & Marcotte, 2007), especially in individuals with frontal lobe and subcortical lesions (Price, Green, & von Studnitz, 1999). The individual’s premorbid proficiency in the languages they speak can influence their ability to maintain the target language.

In addition to language production errors found in monolingual speakers, bilingual and multilingual individuals with acquired brain injury may also demonstrate

  • language-switching errors;
  • semantic/phonological paraphasias produced in the nontarget language; and
  • translation errors.

Speech-language pathologists (SLPs) consider variations in narrative structures secondary to cultural and linguistic factors to ensure that a communication difference is not inaccurately diagnosed as a disorder.

The CDC (2019) identified the following leading causes:

  • Falls and motor vehicle crashes were reported to be the first and second leading causes of all TBI-related hospitalizations (52% and 20%, respectively).
  • Falls accounted for almost half (48%) of all TBI-related emergency department visits and 81% of TBI-related emergency department visits by persons aged 65 and older.
  • Collision-related events (being struck by or against an object) accounted for about 17% of all TBI-related emergency department visits in the United States in 2014.
  • Intentional self-harm was the leading cause of TBI-related deaths (33%) in 2014.

Falls were the leading cause of hospitalizations among adults 55 years of age and older (CDC, 2014). Motor vehicle accidents were the leading cause of hospitalizations for adolescents and adults aged 15–44 years of age. Persons aged 15–24 years and 75 years and older are at the highest risk of sustaining a TBI, with the most common causes attributed to motor vehicle crashes, falls, and violence (CDC, 2014; Faul et al., 2010).

Sports-related injuries and explosive blasts/military combat injuries are other leading causes of TBI. Acquiring a brain injury may predispose an individual to additional brain injuries before symptoms of the first have resolved completely; the second impact is more likely to cause brain swelling and widespread damage (Dessy, Rasouli, & Choudhri, 2015).

Roles and Responsibilities of the SLP

Speech-language pathologists (SLPs) play a central role in the screening, assessment, and treatment of persons with TBI. The professional roles and activities in speech-language pathology include clinical services (assessment, planning, and treatment), prevention, and advocacy, as well as education, administration, and research.

Appropriate roles for SLPs include the following:

  • Identifying risk factors for TBI, considering variability among individuals from different racial and ethnic backgrounds and culturally and linguistically diverse populations
  • Providing prevention information to individuals and groups known to be at risk for TBI as well as to individuals working with those at risk
  • Screening individuals with TBI for hearing, speech, language, cognitive communication, and swallowing difficulties
  • Determining the need for further assessment and/or referral for other services
  • Conducting a comprehensive assessment and diagnosing speech, language, cognitive-communication, and swallowing disorders associated with TBI with sensitivity to individual differences, including cultural and linguistic variations
  • Developing and implementing treatment plans involving direct and indirect intervention methods for maintaining functional speech, language, cognitive-communication, and swallowing abilities at the highest level of independence, with sensitivity to the individual and cultural/linguistic variations
  • Gathering and reporting treatment outcomes, documenting progress, and determining appropriate discharge criteria
  • Facilitating access to comprehensive services, including referral to other professionals as necessary
  • Counseling persons with TBI and their families regarding impairments across the Speech-language pathology scope of practice and providing education aimed at preventing further complications relating to TBI
  • Providing training (e.g., in the use of augmentative and alternative communication [AAC] systems) to persons with TBI and their families and caregivers
  • Serving as an integral member of an interdisciplinary team working with individuals with TBI and their families/caregivers (see ASHA’s web page on interprofessional education/interprofessional practice [IPE/IPP])
  • Consulting and collaborating with other professionals to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate
  • Advocating for individuals with TBI and their families, and educating other professionals, third-party payers, and legislators about the needs of persons with TBI and the role of SLPs in diagnosing and managing speech, language, cognitive communication, and swallowing disorders associated with TBI
  • Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature and treatment of TBI

Roles and Responsibilities of the Audiologist

Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in individuals with TBI.

Appropriate roles for audiologists include the following:

  • Providing prevention information, promoting hearing wellness, and monitoring the acoustic environment
  • Educating other professionals about the needs of adults with hearing and vestibular deficits post-TBI and the role of audiologists in diagnosing and managing them
  • Identifying hearing and vestibular deficits post-TBI, including early detection and screening program development, management, quality assessment, and service coordination
  • Conducting a comprehensive and culturally and linguistically sensitive assessment, using behavioral, electroacoustic, and/or electrophysiological methods to assess hearing, auditory function, vestibular and balance function, and related systems
  • Referring the individual with TBI to other professionals as needed to facilitate access to comprehensive services
  • Evaluating individuals with hearing and vestibular deficits post-TBI for candidacy for amplification and other sensory devices, assistive technology, and vestibular rehabilitation
  • Fitting and maintaining amplification and other sensory devices and assistive technology for optimal use
  • Developing and implementing an audiologic and/or vestibular rehabilitation management plan
  • Creating documentation, including interpreting data and summarizing findings and recommendations
  • Counseling individuals with TBI and their families/caregivers regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence
  • Providing communication skills training for families and other professionals who interact with the individual
  • Serving as a member of an interdisciplinary team working with individuals with TBI and their families/caregivers to provide input on management strategies for vestibular and balance disorders
  • Advocating for the communication needs of all individuals, including advocating for the rights of those with hearing loss, auditory, and/or vestibular disorders and the funding of such services
  • Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits post-TBI

Collaboration and Teaming

Successful management of individuals with TBI typically requires collaboration and teaming with other professionals. For example, dysphagia management may include interdisciplinary teamwork between occupational therapists, dietitians, nursing staff, and the SLP. SLPs may also work with nursing staff (e.g., to facilitate communication between the individual and their medical team) and with physical therapists (e.g., to promote carryover and insight for current limitations and safety).

Interdisciplinary collaboration and teaming also form an integral part of audiology services for individuals with TBI. Audiologists consult and collaborate regularly with other professionals about the individual’s communication management, accessibility to information, the vocational/educational implications of hearing loss and balance problems, and the legal implications of hearing loss and/or other auditory and vestibular dysfunction.


SLPs and audiologists do not diagnose TBI. However, they need to understand the individual’s medical assessment, physical condition, course of recovery, and nature of the neurological damage to guide the development of an appropriate assessment plan (Hegde, 2018).

Assessment of individuals with TBI requires collaboration with the individual and their family members, medical professionals, rehabilitation specialists, and other professionals. Findings from the speech-language and audiology assessments are considered in the context of findings from other professionals on the team.

Assessments are conducted in the language(s) used by the person with TBI, with the use of translation/interpretation services as necessary. Assessments are sensitive to cultural and linguistic variables.


Audiologists and SLPs conduct screening to identify possible deficits following a TBI. Screening is typically completed before conducting more comprehensive evaluations. Screening does not provide a detailed description of the severity and characteristics of deficits resulting from TBI but, rather, identifies the need for further assessment.

Audiologic Screening

Hearing screening and otoscopic inspection for impacted cerumen occur before screening for other deficits. If the individual wears hearing aids, an audiologist should inspect the hearing aids to ensure that they are in working order, and the individual should wear the hearing aids during screening. Hearing screening is within the scope of practice for SLPs.

Referral for a full audiological evaluation is necessary if the individual fails the hearing screening or if hearing loss is suspected. Audiologists may also screen for tinnitus and vestibular deficits as indicated.

Speech, Language, Cognitive-Communication, and Swallowing Screening

SLPs screen for speech, language, cognitive communication, and swallowing deficits using appropriate standardized instruments or nonstandardized procedures. A referral is made for comprehensive assessment in one or more of these areas if the individual fails that portion of the screening.

Comprehensive Assessment

The purpose of a comprehensive assessment for individuals with TBI is to determine speech, language, cognitive-communication, swallowing, and audiology strengths and needs.

If an individual wears prescription eyeglasses or hearing aids, and prescriptions are still appropriate post-injury, then he or she should wear the glasses or aids during the assessment.

If the TBI resulted in additional hearing or visual deficits, then sensory aids and/or accommodations used before the injury may not be sufficient. Physical or environmental modifications may be needed (e.g., large-print material, modified lighting, amplification devices).

If changes to premorbid hearing and/or vision are significant, then the individual is referred for comprehensive audiology and/or vision assessments before any additional testing.

Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF) framework (ASHA, 2016b; WHO, 2001), ongoing comprehensive assessment of individuals with TBI is conducted to identify and describe the following:

  • Impairments in body structure and function, including underlying strengths and weaknesses in areas known to be affected by TBI.
  • Limitations in activities and participation, including functional communication, interpersonal interactions, self-care, and resuming their preinjury roles.
  • Impact of communication impairments on quality of life, functional limitations relative to premorbid social roles, and the impact on his or her community.
  • Contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication and life participation. These can include the following:
    • Facilitators—ability and willingness to use compensatory strategies for day-to-day communication and in the classroom; family support; motivation to improve function.
    • Barriers—decreased confidence in one’s ability to communicate; the presence of cognitive deficits; visual and motor impairments; lack of awareness of disability.

Assessment Methods/Procedures

Assessment protocols can include both standardized and nonstandardized tools and data sources. The decision to use standardized or nonstandardized tools is based upon a variety of factors, including the needs of the person with TBI, the complexity of impairment, payer rules, and facility policy.

Standardized Assessment—Currently, there are few standardized communication assessments for use with individuals with TBI. When selecting a standardized assessment tool, clinicians consider

  • the severity of the underlying neurological damage;
  • the individual’s level of alertness;
  • the presence of comorbid physical, sensory, and cognitive deficits; and
  • cultural and linguistic representation in the norming population.

Tests that are too difficult for individuals with severe deficits will not yield useful information. In addition to selecting tests that assess the targeted areas of deficit, clinicians must also evaluate if the tests selected have been normed for use with TBI.

Nonstandardized Assessment—Functional nonstandardized assessments are particularly valuable because individuals with TBI often perform disproportionately better or worse in activities of daily living compared with abilities predicted by standardized test scores.

Nonstandardized assessment procedures serve a variety of purposes, including identifying

  • the individual’s abilities in domains for which there are no, or limited, standardized tests;
  • the individual’s abilities within functional contexts and activities of daily living;
  • strategies and task modifications to maximize the individual’s functional abilities in various communication contexts;
  • helpful information for communication partners; and
  • outcomes in response to intervention (Coelho, Ylvisaker, & Turkstra, 2005).

Comprehensive Speech-Language Assessment: Typical Components

Case History

  • Nature and onset of TBI and related hospitalizations
  • Medical status—current and before the injury
  • Current medications
  • Review of auditory, visual, motor, and cognitive status
  • Review of emotional and mental status
  • Educational and occupational background
  • Reported areas of concern (e.g., memory, speaking, swallowing) and contexts of concern (e.g., social interactions, work activities)
  • Language(s) used in contexts of concern
  • Impact of current condition on the individual and their family/caregivers
  • Goals and priorities of the individual and their family/caregivers

Nonspeech Examination

  • The integrity of speech subsystems (respiration, phonation, oral articulators)
  • Strength, speed, and range of motion of the oral–motor system components
  • Sequential/alternating movement repetitions (diadochokinesis)
  • Steadiness, tone, and accuracy of movements for speech and nonspeech tasks

Speech Production

  • Vocal quality and ability to change loudness and pitch
  • Stress testing—2 to 4 minutes of reading or speaking aloud to assess deterioration over time to determine if dysarthria is present
  • Motor speech planning or programming—repetition of simple and complex multisyllabic words and sentences to determine if apraxia of speech (AOS) is present
  • Speech intelligibility—the degree to which the listener understands the individual’s speech
  • Speech comprehensibility—the degree to which the listener understands the spoken message, given other contextual information (e.g., topic, context, gestures)


  • Receptive and expressive language skills in oral and written modalities to help distinguish between dysarthria and/or apraxia and aphasia
  • Pragmatic language skills in various communication contexts


  • Aspects of verbal or nonverbal communication that may be affected by disruptions in cognition (e.g., attention, memory, organization, executive function;


  • Swallowing function with various foods and food textures

Other Assessment Components

  • Identification of contextual barriers and facilitators and the potential for effective compensatory techniques and strategies, including the use of cognitive aids and AAC.
  • Identification of relevant follow-up services for appropriate intervention and support.

Comprehensive Audiologic and Vestibular Assessment: Typical Components

Case History

  • Review case history information, including medical information and emotional and mental status
  • Review previous assessments (e.g., speech-language, physical therapy, occupational therapy, audiology)
  • Gather additional details related to hearing, balance, and auditory processing difficulties

Behavioral Hearing Testing

  • Pure-tone and speech audiometry, including modifications (as needed) such as
  • Otoacoustic emissions or auditory brainstem response testing—if accurate test results cannot be obtained using traditional behavioral testing methods

Auditory Processing

  • Speech in noise
  • Temporal processing
  • Binaural processing

Vestibular Testing

  • Dix-Hallpike and roll tests
  • Semicircular canal function tests, such as caloric, rotational, and video head impulse testing
  • Otolith testing, such as (a) ocular and cervical vestibular-evoked myogenic potential (VEMP) and (b) the subjective visual vertical (SVV) test
  • Videonystamography (VNG)

(Fausti, Wilmington, Gallun, Myers, & Henry, 2009; Wintrow, 2013)

General Assessment Considerations

Interdisciplinary collaboration is necessary to maximize the breadth and depth of skills tested and to ensure that the individual is not over-tested or subject to practice effects due to repeated exposure to the same or similar assessment tools.

Depression or anxiety—as a consequence of neurological damage or as a part of the post-traumatic stress disorder complex—can adversely affect test performance. If signs and symptoms of depression are present or suspected, the individual is referred to a neuropsychologist, clinical psychologist, or psychiatrist for follow-up.

The side effects of prescription drugs may affect test performance (e.g., due to excessive drowsiness). Polypharmacy—the concurrent use of several medications—is common among individuals with multiple medical conditions, and some medications may worsen cognitive problems worse.

Repetitive brain trauma contributes—along with other variables—to the development of chronic traumatic encephalopathy (CTE), which in turn influences overall cognitive and behavioral function and increases the risk for dementia (Stern et al., 2011). Therefore, consider the effects of repeated brain injury when determining the prior level of function and baseline skill levels.

Periodic, ongoing assessment is important because neurological recovery can occur for several months or longer after some type of severe brain injury. Ongoing assessment can also be used to examine an individual’s responses to rehabilitation and life after the injury.

Considerations for Cognitive-Communication Assessment

The following factors may influence the assessment of cognitive-communication abilities in individuals with TBI:

  • Level of consciousness and arousal
  • Neurobehavioral deficits, such as agitation and combativeness
  • Motor deficits (e.g., postural limitations. hemiparesis, limb apraxia) that affect physical endurance and participation
  • Sensory deficits (e.g., visual neglect, hearing loss)

Considerations for Swallowing Assessment

Factors that can affect swallowing function following TBI include

  • the extent of brain injury;
  • duration of ventilation and endotracheal intubation and/or presence of a tracheostomy;
  • impairments in positioning and motor control that affect self-feeding;
  • physical damage to the oral, pharyngeal, and/or laryngeal structures;
  • presence of oral and/or pharyngeal sensory disorders;
  • presence of oral and/or pharyngeal movement disorders; and
  • cognitive impairment and behavioral dysregulation (e.g., poor memory, limited insight, impaired sequencing skills, poor judgment and reasoning, and impaired communication).

Consider the patient’s level of arousal, cognitive status, and ability to follow commands throughout the ongoing swallowing assessment. Depending on the individual’s overall alertness and ability to participate, the clinical bedside examination may also include feeding trials of a variety of food textures and liquid consistencies.

Considerations for Audiological and Vestibular Assessment

Comorbidities—including memory and attention deficits, tinnitus, dizziness, and anxiety—can make it difficult to attribute auditory complaints to auditory-only processing deficits and may confound audiological test results.

Balance is a multisensory function. Therefore, during the vestibular assessment, “clinicians working with individuals with blast trauma need to consider several causes of postural instability, including TBI, orthostatic hypotension, cervical vertigo, visual deficits, possible side effects of ototoxic drugs, and vestibular pathology” (Fausti et al., 2009, p. 804).

Considerations for Cultural and Linguistic Variations

When selecting assessment tests, the SLP considers the influence of cultural and linguistic factors on the individual’s communication style and the potential impact of impairment on function.

Clinicians make appropriate accommodations and modifications to the testing process to reconcile cultural and linguistic variations. Comprehensive documentation includes descriptions of these accommodations and modifications. Scores from standardized tests are often invalidated in these cases and may not be appropriate to report. Rather than reporting scores, results can be stated descriptively (e.g., the number and types of errors made on various assessment tasks.)

Due to the complexity of cognitive sequelae in TBI and its influence on bilingual language production (Penn, Frankel, Watermeyer, & Russell, 2010), thorough case history and interviews with the family and individual are particularly useful in identifying premorbid language proficiency, language preference for assessment and treatment of linguistic deficits, and communicative needs in the community (Lorenzen & Murray, 2008).

Treatment of persons with TBI considers

  • personal and contextual factors, such as the individual’s age, education, premorbid status, social history, present social context, and vocational status (current or premorbid);
  • the complex relationship between cognitive domains (e.g., the effect of attention and short-term memory deficits on new learning);
  • the impact of fatigue and limited physical endurance on participation in treatment; and
  • the impact of poor insight and executive function deficits on the ability to (a) recognize breakdowns in function, (b) buy into the potential benefits of treatment, and (c) adhere to specific recommendations (e.g., swallow safety guidelines).

The goal of intervention in TBI is to achieve the highest level of independent function for participation in daily living. Consistent with the ICF framework (WHO, 2001), intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
  • facilitate the individual’s activities and participation by assisting the person in acquiring new skills and strategies; and
  • modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including the development and use of appropriate accommodations.

Interventions that enhance a patient’s activity and participation through modification of contextual factors may be warranted, even if the prognosis for improved body structure/function is limited.

Person- and Family-Centered Care

Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party respects the knowledge, skills, and experiences that the others bring to the process. This approach to care incorporates individual and family preferences and priorities and offers a range of services, including providing counseling and emotional support, providing information and resources, coordinating services, and teaching specific skills to facilitate communication.

Person- and family-centered care for individuals with TBI

  • provides information to the individual, his or her family/caregivers, and other significant persons about the nature of deficits, the course of treatment, and the prognosis for recovery;
  • includes the individual in collaborative decision-making about self-determined goals; and
  • considers input from the family/caregivers and other professionals involved in the individual’s care.

Treatment Approaches

Treatment for TBI can be restorative and/or compensatory. These approaches are not mutually exclusive; aspects of more than one approach often are integrated into the delivery of services.

Restorative approaches involve direct therapy aimed at improving or restoring impaired function(s) through retraining. Treatment is often hierarchical, targeting specific processes in the impaired domain before introducing more demanding higher-level tasks, and eventually generalizing skills to more functional activities and tasks (Sohlberg & Mateer, 2001).

Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health [NIH], 1998). Compensatory approaches draw on the individual’s strengths to maximize his or her abilities, often through the use of external or internal aids.

A compensatory approach to treatment may also include accommodations and/or modifications. Accommodations are changes to the environment, task, or mode of response that allow an individual to access and participate in an activity without changing the activity itself. Modifications are changes to the nature of the activity to facilitate participation and promote success in home, community, academic, and work settings.

Treatment Options

The following are brief descriptions of both general and specific treatments for persons with cognitive communication and swallowing disorders associated with TBI. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement by ASHA.

Augmentative and Alternative Communication (AAC)

Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech and/or writing with aided (e.g., pictures, line drawings, speech-generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. AAC may be temporary (e.g., used by patients postoperatively in intensive care) or permanent (e.g., used by an individual with a disability who will need to use some form of AAC throughout their lifetime).

Factors that influence the selection and use of appropriate AAC systems following TBI include the individual’s communication abilities and needs, as well as their cognitive, neurobehavioral, motor, sensory, and perceptual impairments. Individuals with TBI may rely on assistive technologies to compensate for their cognitive impairments in the absence of linguistic or motor speech disorders (Fried-Oken, Beukelman, & Hux, 2011).

Cognitive-Communication Treatment

Cognitive-communication treatment may focus on restoring skills and/or compensating for deficits. Treatment can address discrete cognitive-communication domains (e.g., attention) or can focus more globally on functional communication.

Cognitive communication treatments include the following:

  • Sensory stimulation—also known as coma stimulation—is the systematic exposure of an individual in a comatose or minimally conscious state to a variety of visual, auditory, tactile, olfactory, and kinesthetic stimuli to improve arousal and level of consciousness and to prevent sensory deprivation (Giacino, Katz, & Schiff, 2006; Thomas, 2018). Sensory stimulation allows for frequent monitoring of an individual’s responsiveness during recovery.
  • Dual-task training focuses on improving task complexity by targeting the ability to carry out two competing tasks simultaneously. Dual-task training is used to restore executive functions often affected by TBI. The tasks can involve any combination of cognitive and/or motor tasks (Evans, Greenfield, Wilson, & Bateman, 2009).
  • Computer-assisted treatment (CAT) refers to the use of specially designed commercial software to improve cognitive communication functions through repeated, structured practice of tasks related to attention, memory, problem-solving, executive function, language, and speech. Software programs adapt tasks; exercises increase in difficulty as performance improves (Lebowitz, Dams-O’Connor, & Cantor, 2012). Software programs are available for use on computers, smartphones, and tablets. Computer-assisted treatment can be used and monitored by a clinician in person or remotely, thus providing consistent feedback to the individual (e.g., Politis & Norman, 2016; Teasell et al., 2013). Instructional or teaching techniques used in cognitive-communication treatment include the following:
  • Direct instruction is a comprehensive instructional technique that involves identifying the target and prerequisite skills; conducting a task analysis to break skills down into smaller steps; providing models; giving consistent and immediate feedback; and providing both massed practice (longer, intensive practice sessions) and spaced/distributed practice (practice broken up into several smaller practice sessions).
  • Strategy-based instruction focuses on the use of various strategies to improve awareness, self-monitoring, and self-regulation.
    • Metacognitive skills training uses goal-setting strategies to facilitate learning and behavioral success. This training uses strategies such as self-talk, self-reflection, mental imagery, and agendas that provide feedback and track progress toward goals. See, for example, Cicerone (2006) and Ownsworth, Quinn, Fleming, Kendall, and Shum (2010).
    • Compensatory strategy training capitalizes on intact skills to overcome deficits resulting from TBI (Wilson, 2002). Compensatory strategies use internal aids and external aids (Shum, Fleming, Gill, Gullo, & Strong, 2011).

      Internal aids are strategies used to enhance memory and executive function (de Joode, van Heugten, Verhey, & van Boxtel, 2010; Gillespie, Best, & O’Neill, 2012; Sohlberg et al., 2007; Wild, 2013). They include mnemonics; visual imagery (Kashel et al., 2002; OʼNeil-Pirozzi, Kennedy, & Sohlberg, 2015); elaborative encoding and association (Oberg & Turkstra, 1998); and chunking (Kennedy, 2006).

      External aids are used to improve attention, time management, organization, and recall of events and information (Burns, 2004; Teasell et al., 2013). Computers and handheld devices, including smartphones and voice recorders, can be used as functional external aids. Low-tech options include calendars, timers, checklists, maps, color-coded binders, and small notebooks (Burns, 2004; DePompei et al., 2008).

  • Errorless learning is an instructional technique that tries to minimize errors as the individual learns a new skill (Ownsworth et al., 2013). Errorless learning involves task analysis to break skills down into smaller steps, modeling before the first attempt at performing the task, giving immediate corrective feedback, and carefully fading supports and prompts (Sohlberg, Ehrhardt, & Kennedy, 2005; Sohlberg & Turkstra, 2011). Spaced/distributed practice may facilitate errorless learning (Melton & Bourgeois, 2005). Errorless learning is most helpful for individuals with relatively unimpaired procedural memory (memory of how to perform certain procedures) and severely impaired declarative memory (memory of facts and events).

Social Communication Interventions

Social communication interventions are designed (a) to improve functional conversational skills, including the use of appropriate pragmatic language norms (e.g., taking turns and remaining on the topic), and (b) to help the individual with TBI navigate social situations.

Components of social communication intervention in adults with TBI include

  • sharing knowledge with, and training, everyday communication partners;
  • situational training to improve social perception and the ability to interpret others’ behavior;
  • situational coaching before challenging situations; and
  • counseling to help an individual identify a sense of self that includes positive social interaction strategies (Ylvisaker, Turkstra, & Coelho, 2005).

Communication partner training (CPT) is an example of a social communication intervention. The goal of CPT is to improve the communication effectiveness of individuals with TBI by training communication partners to use strategies such as

  • providing emotional support;
  • using a positive question style;
  • using collaborative turn-taking; and
  • helping the individual with TBI extend and organize their thinking (e.g., Sim, Power, & Togher, 2013; Togher, McDonald, Tate, Power, & Rietdijk, 2013).

Speech and Voice

TBI can result in dysarthria and apraxia, as well as problems with respiration, phonation, and resonance. Intervention may focus on the individual speech subsystems of respiration, phonation, articulation, and velopharyngeal function or, more globally, on overall verbal communication function using behavioral and instrumental treatments, compensatory strategies, and/or environmental modifications.


The goal of dysphagia treatment is to support safe and efficient oral intake and to ensure adequate nutrition and hydration.

Considerations for dysphagia management in individuals with TBI include

  • cognitive-linguistic deficits (e.g., auditory processing and memory loss) that can affect learning, recall, and use of compensatory swallowing;
  • neurobehavioral deficits (e.g., impulsivity, agitation);
  • perceptual deficits (e.g., visual field neglect);
  • physical limitations that can affect motor control and posture; and
  • sensory impairments that can affect oral intake and swallow safety.

Effective dysphagia management relies on the consistent implementation of compensatory strategies. Deficits in any of the areas noted above can hurt the success of treatment.

Hearing and Balance

Audiologists are integral to the rehabilitation of hearing and balance deficits associated with TBI. Treatment for hearing loss includes the selection and fitting of amplification devices and training in the use of assistive technologies (e.g., hearing assistive technology [HATS]).

The treatment goals for balance disorders associated with TBI are (a) to promote the central nervous system’s natural compensation processes to reduce or eliminate symptoms, (b) to decrease the individual’s sensitivity to symptom-provoking movements, and (c) to reduce the risk of falls.

Audiologists are also involved in the management of tinnitus associated with TBI. Management can include the use of hearing aids, sound masking, counseling, and cognitive-behavioral interventions.

Treatment for audiology-related symptoms may include counseling about the use of coping and compensatory skills that can minimize the effects of hearing and balance disorders and reduce safety risks.

Cultural and Linguistic Considerations

Treatment considers the cultural values and norms of the individual. Different dimensions of culture may influence an individual’s views on seeking care and external support following a TBI. For example, some cultures may have a sense of shame or feel the need to hide a disability. This may influence how an individual and their family/caregivers approach treatment. Treatment is also sensitive to linguistic diversity. It is provided in the language(s) used by the individual with TBI.

Transitioning After TBI

Individuals with persistent cognitive-communication deficits after a TBI may continue to face challenges as they return to work or academic settings and manage daily activities such as shopping and handling finances (e.g., Colantonio et al., 2004; Kennedy, Krause, & Turkstra, 2008; Meulenbroek, Bowers, & Turkstra, 2016; Meulenbroek & Turkstra, 2016).

The potential impact of persisting deficits highlights the need for continued support. The role of the SLP is to identify communication-related deficits, determine how they might affect the individual in various settings, and design treatment approaches to minimize the impact of these deficits.

Considerations in Work Settings

The nature of deficits associated with TBI creates unique challenges in work settings. Fatigue, sensory issues, health concerns, and cognitive-communication deficits (e.g., language processing, reading and writing, verbal reasoning, memory, and pragmatics) can hurt performance (see, e.g., Meulenbroek et al., 2016; Meulenbroek & Turkstra, 2016).

The SLP identifies current cognitive-communication deficits, determines how these may affect life skills and job performance, and then trains the individual on strategies they can use to minimize the impact of the deficits in work settings (Bonelli, Ritter, & Kinsler, 2007). The SLP collaborates with counselors and psychologists, vocational rehabilitation specialists, job coaches, and employers, as appropriate, to help implement necessary accommodations for maximum outcomes.

Individuals with TBI may be eligible for protection in the workplace under Section 504 of the Rehabilitation Act of 1973. This law protects qualified individuals from discrimination based on their disability. Section 504 prohibits employment discrimination against individuals who meet job requirements and can perform essential job duties with or without reasonable accommodations. It may also provide vocational training and employment services for eligible individuals. SLPs can give input about reasonable accommodations to minimize the effects of cognitive-communication deficits. These include providing written task instructions and using time management devices to help the individual stay on task.

Considerations in Academic Settings

Attention, memory, learning, executive function, and social-emotional impairments—coupled with self-regulation challenges—place individuals with TBI at greater risk for failure in academic settings (Kennedy et al., 2008).

The SLP can provide support to individuals in college (and vocational training programs) by identifying systems and services to facilitate studying, learning, and time management, and by training individuals to use compensatory strategies and promoting self-advocacy (Kennedy & Krause, 2011; Turkstra, Gamazon-Waddell, & Evans, 2004; Volkers, 2015).

Disability support services staff may collaborate with SLPs to select courses, modify schedules, and implement accommodations (under Section 504 or similar plans, if applicable). Accommodations might include notetakers, extended time for tests and assignments, and assistive technology (e.g., text-to-speech and speech-to-text devices that help with reading and writing tasks).

Service Delivery

In addition to determining the optimal treatment approaches for individuals with TBI, SLPs consider other service delivery variables—including formatproviderdosage, and timing—that may affect treatment outcomes.


The format is the structure of the treatment session (e.g., group vs. individual). Group therapy can provide individuals with TBI an opportunity to initiate social interaction in a structured environment with feedback from the clinician and peers. The combination of individual and group therapy is more effective in reaching functional goals than the group format alone (Tate et al., 2014).

Technology has been incorporated into the delivery of services for TBI, including the use of telepractice to deliver face-to-face services remotely. Videoconferencing and interactive skills-based programs via telepractice may be more meaningful for providing support and information to caregivers than self-guided web sessions (Rietdijk, Togher, & Power, 2012). Telepractice may allow clinicians to help patients practice skills in the context in which those skills will be used (Turkstra, Quinn-Padron, Johnson, Workinger, & Antoniotti, 2012).


Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver). Cognitive rehabilitation is most successful in the context of the individual’s needs and current living environment. Family members and significant others play a critical role in supporting the individual with TBI and augmenting the treatment plan. Training that incorporates everyday communication partners may allow partners to facilitate carryover beyond the training sessions (Togher et al., 2014).


Dosage refers to the frequency, intensity, and duration of service. Clinicians consider the individual’s arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity when determining the appropriate frequency, intensity, and duration of services.


Timing refers to the timing of intervention relative to the injury. Treatment typically begins with assessment in the acute or rehabilitation inpatient setting and may continue in post-acute care (e.g., post-acute rehabilitation).


Setting refers to the location of treatment (e.g., home, community-based). Clinicians consider the individual’s functional abilities and goals and how best to facilitate carryover when determining the most appropriate setting for intervention. Time-limited residential programs and community-based programs are available in some areas to foster community integration and provide peer support.


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