Concussion and mild brain injuries: When Intervention from a speech-language pathologist is reasonable and necessary.
Sheila MacDonald M.Cl.SC. Reg. CASLPO. SLP (C) Sheila MacDonald & Associates, Guelph, Ontario
Mild brain injuries and concussions can result in persisting difficulties that interfere with work or school. No two injuries are alike and assessment and planning for re-integration and re-activation requires clinical expertise and analysis of multiple individual factors. Current evidence supports assessment, education, and in some cases, treatment of individuals with persisting cognitive and communication difficulties after a mild brain injury.
Speech-language pathologists assess and treat cognitive-communication difficulties that can occur from a variety of causes. Cognitive-communication deficits are difficulties with communication (listening, speaking, reading comprehension, written expression, or social communication) that occur because of underlying cognitive difficulties (attention, memory, organization, reasoning, executive functions, or self regulation). These difficulties can arise from a variety of causes (brain injury, pain, post traumatic stress disorder, depression, fatigue etc.). A diagnosis of a brain injury or psychological causes is made by a physician or a psychologist. The speech-language pathologist carefully reviews the case history, including any diagnostic statements. In many cases the diagnosis is as yet undetermined or equivoc.al with different diagnosticians stating a variety of diagnoses. The SLP assessment involves the thorough analysis and integration of individual and family reports of daily functioning, standardized test performance, functional evaluation, and available case history. Collaboration with other professionals and judicious communication of findings is essential. Regardless of the diagnosis, the speech-language pathologist can provide helpful practical strategies to assist the person with daily communications. Often it is the case that a focus on functional re-integration is more helpful than multiple assessments and diagnostic deliberation. The SLP approach will be a function first approach that focuses on the individual’s unique situation and their specific needs for supports and strategies to assist with gradual return to work, school, and community communications.
Persisting Deficits are common following Mild Brain Injuries
- Most difficulties after a mild brain injury resolve within the first 3 months.
- As many as 10 to 40% of individuals may have persisting deficits following mild brain injury. Studies vary depending on the type of injury, time post onset, and the outcome measures used (Rabinowitz et al, 2014; Sveen et al, 2013; Levin & Robertson, 2013; Marshall et al, 2012; Ontario Mild Brain Injury Guidelines, 2013; Sigurdardottir et al, 2009; Bigler, 2008). A rate of 15% persisting difficulties is typical in recent studies.
- Approx 15 % of children with mild brain injuries experience persisting deficits 6 months post injury (Srouffe et al, 2010 ). Persisting difficulties with work and school have been demonstrated many years post injury in some children with mTBI (McKinlay et al, 2009)
Cognitive-Communication Difficulties are common following Mild Brain Injury
- Cognitive-communication difficulties are common following mild brain injuries of many types including: motor vehicle crashes, sport concussions, falls, blast injuries, hypoxia or loss of oxygen to the brain (drowning, carbon monoxide poisoning, cardiac arrest) and other acquired neurological diseases (encephalitis, Lyme disease, West Nile virus etc.)
- These findings are consistent in adults and children, although children are more significantly impacted by age at onset.
- Based on the available research across multiple populations, it is estimated that the incidence of cognitive-communication disorders in individuals with mild brain injuries is as high as 60% (studies vary depending on the cause, severity, time post onset, and measurement characteristics).
- These deficits result in difficulties with return to school, work, and social interaction
- Thorough assessment of cognitive communication deficits by a speech-language pathologist is warranted after mild brain injuries.
- Barwood & Murdoch, 2013; Cherney et al, 2010; CornisPop et al 2012; Fitzgerald et al, 2012; Finke et al, 2011; Hahn et al, 2012; Mealings & Douglas, 2010; Riegler et al, 2013; Parrish et al, 2009; Sonnenberg et al, 2010; Sveen et al, 2013; Gerrard-Morris et al, 2010; Kennedy et al, 2008; Tager et al, 2010; Whelan et al, 2007;Tucker and Hanlon, 1999;)
Cognitive-communication deficits interfere with return to work and school
- 34% of those with MTBI had not returned to work at 6 months post injury due to injury related difficulties (Boake et al , 2005)
- 44% of those who had returned to work reported having difficulties related to cognition or communication or both (Boake et al, 2005)
- 75% of those with mild brain injuries had difficulties with return to work (Sveen et al, 2013)
- Early mild brain injury can disrupt later development of higher level cognitive-communication skills. Difficulties have been reported in such things as : listening, new learning, reading and retaining, classroom participation, studying & test writing, assignment completion, behavioural regulation, social communication (Anderson et al, 2009; Sonnenberg et al, 2010; Mealings & Douglas, 2010; Ciccia et al, 2009; Haarbauer Krupa, 2012)
- 80% of college students with a traumatic brain injury had persisting academic difficulties (Kennedy et al, 2008)
Traditional diagnostic indicators are often not sensitive enough to detect mild brain injury (e.g. CT, MRI, Loss of Consciousness, Glasgow Coma Scale Score; Traditional standardized tests). More sensitive measures are required to detect persisting neurological, neurochemical, and neurocognitive deficits
- CT and MRI not effective in detecting majority of mild brain injuries (Levin & Diaz-Arrastia, 2015; Rabinowitz et al, 2014;Bazarian, 2006; Graner et al, 2013)
- Loss of consciousness is not a reliable indicator as the majority of individuals who sustain mild traumatic brain injuries do not lose consciousness (Luis et al, 2013; Ruff et al, 2009)
- Traditional neuropsychological measures may not detect persisting deficits (Bigler, 2008)
- More sensitive measures may include diffusion tensor imaging, and functional forms of evaluation that simulate the complex cognitive-communication demands of daily life (Rabinowitz et al, 2014, Bazarian, 2006; Bigler, 2008; Hanten et al, MacDonald & Johnson, 2005)
Interventions for cognitive-communication deficits are evidence based.
- Assessment of cognitive-communication disorders by a speech-language pathologist after brain injury is warranted, even after mild brain injury. This is best practice supported by large studies of 40,000 individuals as well as international guidelines (Norman et al, 2013; Togher et al, 2014;)
- Speech-language pathology intervention is multifaceted and includes: education, individualized goal setting, provision of strategies, guided and graded practice, feedback, compensatory techniques, implementation of supports, communication partner training, and use of instructional and self-regulatory techniques.
- Cognitive-communication interventions including interventions for persisting deficits after mild brain injuries, are supported by the research evidence. (Griffiths et al, 2015; Vas et al, 2014; Cook et al, 2014; Cantor et al, 2014; Wheeler et al, 2014; Riegler et al, 2012; O’Neil Pirozzi et al, 2010; Melton & Bourgeois 2005; Cicerone et al, 2011; MacDonald & Wiseman-Hakes, 2010; Lee et al, 2011; Sohlberg et al, 2003)
- There have been calls for improved quality of research across all fields in acquired brain injury with a call for more randomized controlled trials. Research quality pertaining to cognitive-communication interventions has been consistent with that in other fields of intervention (McIntyre et al, 2015) and studies of communication interventions are among the most prevalent (Perdices et al, 2006). Randomized controlled trials, which are considered to be the gold standard in evidence based research, are building including studies involving interventions developed or delivered by speech-language pathologists for individuals with mild brain injuries (Vas et al, 2014; Cantor et al, 2014; O’Neil Pirozzi et al, 2010; Bourgeois et al, 2007).
- Speech-language pathology interventions have been shown to be beneficial even when there are co-occurring conditions (eg. post traumatic stress disorder, pain, substance abuse). When co-occurring deficits are present a collaborative, multidisciplinary approach is indicated. (Braden et al, 2010; Riegler et al, 2012; Parrish et al, 2009; Cornis-Pop et al; Cherney et al 2010).
- Recent research supports the view that the presence of comorbid PTSD or depressive symptoms in individuals with mild brain injuries should not preclude participation in cognitive rehabilitation interventions including interventions designed by speech-language pathologists (Walter et al, 2015). In fact, cognitive strategy training has been shown to lower scores for depression and PTSD (Huckans et al, 2010).
Therefore: referral to a speech-language pathologist is indicated if cognitive-communication deficits persist beyond 12 weeks post mild acquired brain injury. A cognitive-communication assessment is warranted to assist with planning supports and strategies for return to work or school. Education and functionally oriented intervention from an SLP after mild brain injury are evidence based. __________________________________________________________________________
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