Traumatic Brain Injury
Injury to the head (traumatic brain injury, or TBI) may cause interference with normal brain functions. There are two broad categories used to describe TBIs:
Penetrating Injuries: In these injuries, a foreign object, e.g., a bullet, enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.
Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, when the head strikes the windshield or dashboard of a car. These injuries cause two types of brain damage:
· primary brain damage, damage that is said to be complete at the time of impact, and
· secondary brain damage, damage that evolves over a period of hours to days after the trauma.
Primary injuries may include some or all of the following:
Skull fracture: Breaking of the bony skull
Contusions/bruises: Often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull
Hematomas/blood clots: Occur between the skull and the brain or inside the brain itself
Lacerations: Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain (The force of the blow causes the brain to rotate across the hard ridges of the skull causing the tears).
Diffuse axonal injury: Arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers.
Secondary injuries may include brain swelling (edema), increased pressure inside of the skull (intracranial pressure), epilepsy, intracranial infection, fever, hematoma, low or high blood pressure, low sodium, anemia, too much or too little carbon dioxide, abnormal blood coagulation, cardiac changes, lung changes, and nutritional changes.
Physical problems may include hearing loss, tinnitus (ringing or buzzing in the ears), headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, reduced strength and coordination in the body, arms, and legs.
Individuals with a brain injury often have cognitive and communication deficits that significantly impair their ability to live independently. These deficits vary depending on how widespread brain damage is and the location of the injury.
Brain injury survivors may have trouble finding the words or grammatical constructions they need to express an idea or explain themselves through speaking and/or writing, as if the words they need are "on the tip of their tongues." It may be an effort for them to understand both written and spoken messages, as if they were trying to comprehend a foreign language. They may have newfound difficulties with spelling, writing, and reading, skills that presented no problem prior to their injury.
Deficits in social communication skills may alter the individual's ability to take turns in conversation, maintain a topic of conversation, use an appropriate tone of voice, interpret the subtleties of conversation (e.g., the difference between sarcasm and a serious statement), respond to facial expressions and body language, or keep up with others in a fast-paced conversation. Individuals may seem overemotional (overreacting) or "flat" (without emotional affect). Most frustrating to families and friends, a person may have little to no awareness of just how inappropriate he or she is acting. In general, communication can be very frustrating and unsuccessful.
In addition to all of the above, functioning of speech muscles may also be affected. Muscles of the lips and tongue may be weaker or less coordinated affecting the ability to speak clearly. Breathing muscles may be weaker, affecting the ability to speak loud enough to be heard in conversation. Muscles may be so weak that the person is unable to speak at all. Weak muscles may also limit the ability to chew and swallow effectively.
Cognition refers to thinking skills. Cognition includes an awareness of one's surroundings, sustained attention to tasks, memory, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking). Cognitive difficulties are highly common in persons who are traumatically brain injured, and problems again vary depending on the location and severity of the injury to the brain.
Patients frequently have trouble concentrating when there are internal and external distractions, e.g., carrying on a conversation in a noisy restaurant or dividing attention among multiple tasks/demands.
The processing or "taking in" of new information is generally slower. Longer messages may have to be "chunked," or broken down into smaller pieces. The patient may have to repeat/rehearse incoming messages to make sure he or she has processed the crucial information. Communication partners may have to slow down their rate of speech to accommodate the patient's processing needs.
Recent memory is affected, making new learning difficult, e.g., students may have trouble learning and retaining new concepts taught in class. Long-term memory for events and things that occurred pre-injury, however, is generally unaffected, e.g., the patient will remember names of friends and family.
Impairments in executive functioning diminish the ability to initiate tasks and set long-term and short-term goals for task completion. Planning and organizing the job at hand is an effort, and it is difficult to self-evaluate work. Consequently, these individuals seem disorganized and unable to negotiate their lives without the assistance of families and friends. They also may have difficulty solving problems, and they may react impulsively (without thinking first) to situations.
The Speech-Language Pathologist (SLP)
The speech-language pathologist works collaboratively with other rehabilitation and medical professionals (doctors, nurses, neuropsychologists, occupational therapists, physical therapists, social workers, employers, and teachers) and families to provide a comprehensive evaluation and treatment plan for the patient with traumatic brain injury.
The speech-language pathologist completes a formal evaluation of speech and language skills. An oral motor evaluation checks the strength and coordination of the muscles that control speech. Understanding and use of grammar (syntax), understanding and use of vocabulary (semantics), reading and writing are evaluated. The SLP will evaluate the person's ability to relate an extended narrative (language sample). Can he or she explain something or retell a story, centering on a topic and chaining a sequence of events together in a logical order? Is narrative coherent or is it difficult to follow?
Social communication skills (pragmatic language) are evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to discuss stories and the points of view of various characters. Does he or she understand how the characters are feeling, and why they are reacting a certain way? Can he or she explain how different characters' actions affect what happens in the story? The person may be asked to interpret/explain jokes, sarcastic comments, or absurdities in stories/pictures (e.g., what is strange about a person using an umbrella on a sunny day?).
The speech-language pathologist will assess cognitive-communication skills. Is the person aware of surroundings? Does he or she turn towards a voice? Does the person know his or her name, the date, where he or she is, what happened to him or her (orientation)? Recent memory skills are assessed, e.g., whether the main details in a short story are retained. Executive functioning is evaluated. The speech-language pathologist assesses the patient's ability to plan, organize, and attend to details (e.g., completing all of the steps for brushing teeth). The SLP may read an incomplete story and ask for a logical beginning, middle or conclusion. The person may be asked to provide solutions to problems (reasoning and problem solving). For example, what would you do if you locked your keys in your car? How can this problem be avoided in the future?
If there is difficulty swallowing, the speech-language pathologist will evaluate this function, and work with a dietician and physician to make recommendations regarding food consistency (e.g., pureed versus chopped food). The focus of this evaluation will be to insure that the individual is able to swallow safely, without accidentally inhaling food into his or her lungs (aspiration).
If necessary, the speech-language pathologist may also evaluate the benefit of a communication aid or device to express basic needs and ideas.
The treatment program will vary depending on the stage of recovery, but it will always focus on increasing independence in everyday life.
In the early stages of recovery, e.g., during coma), treatment focuses on getting general responses to sensory stimulation. The family is given information about the best techniques for interacting with the loved one.
As an individual becomes increasingly aware of surroundings, treatment will focus on helping to sustain attention for basic activities. The speech-language pathologist will also work to decrease the patient's confusion by orienting him or her to the date, to where he or she is, and what has happened.
Later on in recovery, treatment will focus on helping the person compensate for difficulties remembering (e.g., using a memory log to keep track of daily happenings). The person will work with the clinician individually and in small groups to learn strategies to help problem solving, reasoning, and organizational skills. He or she may work in social skills groups to help with conversational skills. Treatment will always focus on increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community.
Eventually, individuals may be taken on community outings to practice outside the hospital what they have learned. They are asked to plan, organize and carry out these trips using memory logs, organizers, checklists, and other helpful aids. Later on in recovery, the speech-language pathologist may work with a vocational rehabilitation specialist to help with transition back into work or school or with employers and/or educational specialists to implement strategies in these settings. The SLP may work on modifying the work/school environment to meet the person's cognitive needs.
Individual therapy may focus on improving language skills as needed. If weak musculature is an issue for speaking and swallowing, treatment will focus on strengthening affected muscles for talking and eating. If the person is learning how to use an augmentative or alternative communication device, treatment will focus on increasing efficiency and effectiveness with the device.
Who Is Affected?
Approximately 500,000 individuals sustain traumatic brain injuries in the United States each year (200 per 100,000 population). Within this group, approximately 200,000 individuals die; 50,000 to 100,000 of them survive with significant impairments to prevent them from living independently. More than 200,000 of them have continuing problems that interfere with daily living. Males, especially those between the ages of 15 and 24, are nearly twice as likely to sustain a traumatic brain injury as females. There is also an increased risk of traumatic brain injury among those older than 75 and younger than 5.
The following web sites can provide information and support for patients and their families and friends:
NIDRR TBI Homepage: www.tbims.org
The Coma Waiting Page: www.waiting.com
The Brain Injury Association: www.biausa.org/
The Brain Injury Information Network: www.tbinet.org/
The Head Injury Awareness Foundation: www.hiaf.org/
The TBI Chatroom: www.tbichat.org/
Head Injury Hotline (a non-profit clearinghouse founded and operated by a head injury activitist since 1985) www.headinjury.com