What is a Traumatic Brain Injury?

A traumatic brain injury (TBI) is an acquired brain injury that is the result of an external physical force to the head or other way of dislodgement of the brain. There can be focal damage in an open head injury, such as a gunshot wound, or diffused damage in a closed head injury, such as a concussion. Although TBIs can affect people in any age group, adolescents (15-19 years old) and the elderly (65+ years old) are most likely to be affected. Males are more likely than females to suffer TBIs across all age groups.  

Causes of Traumatic Brain Injuries

Some possible causes of TBIs are:  

• Falls: Falls can occur anywhere at any time. Falls in the bath or shower and on the stairs are extremely common in young children and older adults.  
• Traffic Collisions: Collisions can affect both motor vehicle passengers and pedestrians. Motor vehicle accidents are a large contributor to TBIs.  
• Sports-related injuries: High impact or extreme sports have become more common and are another cause of increased TBIs.
• Common sports with high levels of TBIs are football, boxing, hockey, lacrosse, and soccer.  
• Violence: Violence including child abuse, shaken baby syndrome, gunshot wounds, domestic violence, and assault can all lead to TBIs.  o Explosions and combat injuries: Military personnel is exposed to blasts and combat injuries such as falling debris and shrapnel that can lead to TBI.  

Progression of Traumatic Brain Injuries 

• Directly after the injury, the result is usually some type of loss of consciousness. The severity can be anywhere from losing consciousness for a few moments to a coma lasting years. The longer the coma, the more severe the injury and the greater the chance of permanent cognitive damage. 
• After awakening from the coma, post-traumatic amnesia occurs. This is a state of severe confusion. Symptoms include blank stares, difficulty performing simple tasks, distractibility, and memory issues. There are also uncharacteristic behavioral changes. The patient is typically unaware of these impairments. 
• Patients then begin retaining information, entering the recovery stage. This can last anywhere from weeks to years, depending on which areas of the brain are affected and the severity of the damage. This is characterized by improving cognitive and behavioral functions. This usually occurs rapidly at first, but then slows until the recovery stabilizes. 

Neuropathology

• When the brain is subjected to trauma, it goes into a violent swirling motion. As a result, the motion stretches axons, tears blood vessels, and inflicts damage to the surface of the brain from bouncing against the bony ridges of the skull. 

Signs and Symptoms of TBIs 

• Physical problems involve headaches, dizziness, changes in the level of consciousness, seizures, nausea/vomiting, reduced muscle strength, and impairments in balance, movement, and/or coordination. 
• Sensory deficits depend on the areas of the brain involved. 
• Behavioral changes involve changes in emotion, agitation, anxiety, and depression. People can also experience impulsivity and reduced frustration tolerance. 
• Impairments in thinking skills can involve changes in awareness of surroundings, attention issues, reasoning and problem-solving, and executive functioning. New learning is affected by these memory deficits, however, long-term memory is usually unaffected. The patient may also seem disorganized and have trouble completing tasks. 
• Communication issues often include aphasia, or difficulty understanding and producing correct speech; dysarthria, or slurred speech from weak muscles; and/or apraxia, or trouble programming the muscles to produce speech. Some people may also have trouble with tasks in reading and writing, as well as communicating and behaving in social situations. 
• Swallowing problems, or dysphagia, can also occur. 

Signs and symptoms specific to SLP/Audiologist: 

• Lack of strength/coordination in muscles that control speech 
• Misuse of grammar and vocabulary 
• Reading and writing abilities are hindered 
• Social communication skills are hindered 
• Attention, orientation, and short-term memory skills are not in tact 
• Lack of ability to plan, organize and attend to details 
• Ear aches 
• Loudness sensitivity 
• Hearing impairments 
• Distorted hearing 
• Dizziness/vertigo 

Diagnosis of TBIs 

• TBI is diagnosed from a combination of patient reports, clinical signs and symptoms, and brain imaging studies, such as MRIs or CT scans. The medical diagnosis is made by the physician. 
• The specific problems that result from the TBI are diagnosed and managed by the interdisciplinary team, which includes doctors, nurses, speech-language pathologists, audiologists, physical and occupational therapists, and more. 

Assessment Techniques: 

Screening is conducted to determine if further assessment is necessary. A speech-language pathologist will screen for speech, language, cognitive communication, and swallowing using standardized and non-standardized procedures. An Audiologist conducts a hearing screening to determine if the earwax is impacted. Individuals thought to have communication or swallowing deficits are referred for a more comprehensive assessment. 

Assessment includes: 

• A case history that includes medical status, education, occupation, and cultural and language backgrounds. 
• Auditory, visual, motor, cognitive and emotional statuses are analyzed. 
• The systems involving speech are analyzed as well as swallowing. 
• Standardized and non-standardized methods are used and accommodations can be made to fit the individual’s culture and language. 
• The decision to use standardized or non-standardized methods is based upon the needs of the patient and the severity of the injury. 
• The individual’s areas of concern are noted and taken into consideration during assessment. 
• Assessments are conducted periodically and continually because an individual’s recovery can take several months to years. 

Prevention: 

• To help prevent head injury be sure to follow these tips: 
• Wear a seatbelt when riding in any motor vehicle and be sure that children are properly secured in car seats and booster seats in the back seat of the car.  
• Avoid driving or participating in other risky behaviors while under the influence of alcohol, drugs, or prescription medication that can cause impairments.  
• Wear a helmet when riding a bike, skateboard, motorcycle, or another high-speed vehicle. Also, be sure to wear protective headgear when participating in high-impact sports with the potential for brain injury.  
• Pay attention to what is going on around you. Be sure to pay attention around busy streets and areas where falls can occur such as around stairs or ladders. 

Preventing Falls in Older Adults: 

• Install and use handrails near stairs and in the bathroom  
• Use a nonslip mat in the shower to prevent slips  
• Remove loose area rugs throughout the house  
• Be sure to have appropriate lighting throughout the house and especially in bathrooms and near stairways   Keep the floors and stairs clear from debris  
• Be sure to get your vision checked regularly  

Preventing TBI in children: 

• Some ways to help prevent TBI in children are to: 
• Install safety gates near the stairs to prevent falls.  
• Keep the stairs clear and hold hands when appropriate  
• Install window guards and ensure windows are locked  
• Place nonslip mat in the bath or shower  
• Make sure there are no loose rugs in the house that could cause tripping  
• Don’t let children near fire escapes or high balconies  

Speech Therapy Following a TBI

Speech therapy following a Traumatic Brain Injury (TBI) entails far more than relearning how to speak. TBI can often affect a person’s speech, language, cognition, memory, and/or swallowing abilities. Depending on which area of the brain is injured and the severity of the damage, one or more skills could be affected. 

Following a TBI, communication issues often include aphasia, (i.e.,  difficulty understanding and producing correct speech); dysarthria, (i.e., slurred speech from weak muscles; lack of strength/coordination in muscles that control speech); and/or apraxia, (i.e., trouble programming the muscles to produce speech). Some people may also have trouble with reading and writing tasks, as well as communicating and behaving in social situations. Cognition (e.g., attention, reasoning/problem solving, orientation, executive functioning) and short-term memory skills are also often impacted. Swallowing difficulties (i.e., dysphagia) can also occur.

The role of speech therapy in the rehabilitation process of a person who has suffered a TBI is essential. Speech therapists can help a person who has suffered a TBI rehabilitate his/her abilities through speech therapy activities. The treatment plan for a patient who has suffered a TBI depends on his/her condition, the area of the brain affected, and the extent of brain damage. 

There are several ways that speech therapy can help a patient who has suffered a TBI in his/her recovery, including therapy for aphasia, dysarthria, apraxia, improved memory skills, and social communication skills, as well as, cognitive communication skills. Speech therapists help patients who have suffered a TBI develop compensatory strategies to focus on and maximize/her remaining skills, as well as, find ways to compensate for lost skills. 

Speech therapists work with TBI patients, starting from the early stages of recovery. The goal of treatment is to gain confidence and reach the highest level of independent function for daily living. 

Early stages of recovery, such as during the coma, involve getting general responses to sensory stimulation and teaching loved ones and family members how to interact with the patient.

As the patient’s awareness increases, treatment shifts to focusing on maintaining attention, lessening confusion, and familiarizing him/her with the date, what has happened, and where he/she is (i.e., self, place, and temporal/time orientation). 

Later in the recovery process, the focus moves to memory improvement through activities and compensatory strategies, such as memory logs; learning tactics to aid in problem-solving, reasoning, and organizational skills; working on social skills in small settings; and improving the ability to self-monitor while in the hospital, at home, and in the community. 

In the end, treatment focuses on independence and functionality. Treatment can include attending outings to help the patients plan, organize, and carry out their trips using lists, organizers, and other aids. Patients put into practice what they have learned through speech therapy. Speech therapists often work closely alongside vocational rehabilitation specialists to help the patient get back to school and/or work. 

Following a TBI, some patients cannot speak clearly for an extended period. Speech therapists may recommend other ways to communicate. Augmentative or Alternative Communication (AAC) includes picture boards and speech generating devices that speak for you. AAC options include: 

• No-tech communication tools: gesturing/pointing to communicate
• Low-tech communication tools: using pen/paper, whiteboard, or pictures to communicate
• High-tech communication tools: using text-to-speech/communication apps, and communication devices to communicate

If an AAC tool/device is being used for communication, treatment will often focus on learning how to use the tool/device efficiently and effectively to communicate with caregivers, loved ones, and people in the community. 

If a patient has a Traumatic Brain Injury, the therapists at Niagara Therapy can help improve overall function through the services offered, including, Speech Therapy, Occupational Therapy, and Physical Therapy.  

Additional Resources: 

• http://www.asha.org/public/speech/disorders/TBI/ 
• http://www.traumaticbraininjury.com/ 
• http://www.ninds.nih.gov/disorders/tbi/tbi.htm 
• http://www.asha.org/aud/articles/CurrentTBI/