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 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. __________________________________________________________________________



Barwood, C. H. S., & Murdoch, B. E. (2013). Unravelling the influence of mild traumatic brain injury (MTBI) on cognitive-linguistic processing: A comparative group analysis. Brain Injury : [BI], 27(6), 671–6.

Bazarian, J. J., Blyth, B., & Cimpello, L. (2006). Bench to bedside: evidence for brain injury after concussion–looking beyond the computed tomography scan. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 13(2), 199–214. doi:10.1197/j.aem.2005.07.031

Bigler, E. D. (2008). Neuropsychology and clinical neuroscience of persistent post-concussive syndrome INTRODUCTION : BRIEF HISTORY, 1–22.

Boake, C., McCauley, S., Pedrosa, C., Levin, J., Brown, S., & Brundage, S., (2004). Lost productive work time after mild to moderate traumatic brain injury with and without hospitalization. Neurosurgery, 56(5) : 994-10003.

Bourgeois, M.S., Lenius, K., Turkstra, L., & Camp, C. (2007) The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain injury:  21(12), 1245-57.

Braden, C., Hawley, L., Newman, J., Morey, C., Gerber, D., & Harrison-Felix, C. (2010). Social communication skills group treatment: a feasibility study for persons with traumatic brain injury and comorbid conditions. Brain Injury : [BI], 24(11), 1298–310.

CASLPO, C. C. D. (2002 Revised 2015). College of audiologists & speech-language pathologists of Ontario.                                                  Injury, 2–41.

Ciccia, A. H., Meulenbroek, P., & Turkstra, L. S. (2009). Adolescent brain and cognitive developments. Context, 29(3), 249–265.

Cherney, L. R., Gardner, P., Logemann, J. A., Newman, L. A., Neil-pirozzi, T. O., Roth, C. R., & Solomon, N. P. (2010). The Role of Speech-Language Pathology and Audiology in the Optimal Management of the Service Member Returning From Iraq or Afghanistan With a Blast-Related Head Injury : Position of the Communication Scienc &Disorders Clinical Trials Research Group. Health (San Francisco), 25(3), 219–224.

Cook L, Chapman S., Elliott, A, Evenson N., Vinton K. (2014) Cognitive gains from gist reasoning training in adolescents with chronic stage traumatic brain injury. Frontiers in neurology. 5(87): 1-9.

Cognitive gains from gist reasoning training in adolescents with chronic-stage traumatic brain injury Lori G. Cook 1,2* † , Sandra B. Chapman1,2† , Alan C. Elliott 3 , Nellie N. Evenson1 and Kami Vinton1Cornis-Pop, M., Mashima, P. a, Roth, C. R., MacLennan, D. L., Picon, L. M., Hammond, C. S., … Frank, E. M. (2012). Guest editorial: Cognitive-communication rehabilitation for combat-related mild traumatic brain injury. Journal of rehabilitation research and development, 49(7), xi–xxxii. Retrieved from

Gerrard-Morris, A., Taylor, H. G., Yeates, K. O., Walz, N. C., Stancin, T., Minich, N., & Wade, S. L. (2010). Cognitive development after traumatic brain injury in young children. Journal of the International Neuropsychological Society : JINS, 16(1), 157–68. doi:10.1017/S1355617709991135

Graner, J., Oakes, T. R., French, L. M., & Riedy, G. (2013). Functional MRI in the investigation of blast-related traumatic brain injury. Frontiers in neurology, 4(March), 16.

Griffiths GG, Sohlberg MM, Kirk C, Fickas S, Biancarosa G (2015) Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury. Neuropsychological Rehabilitation. Feb 25:1-30. [Epub ahead of print]

Haarbauer-krupa, J. (2012). Taking Care of Children After Traumatic Brain Injury, Perspectives. 79–86.

Hahn, K., Schildmann, E., Baumeister, C., Von Seggern, I. (2012) Cognitive impairment after acute encephalitis: An ERP study. International Journal of Neuroscience, 122, 630‐36.

Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L.Engel, C.C. & Castro, C.A.  (2008) Mild traumatic brain injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine. 358 (5): 453-463.

Halstead, M. E., & Walter, K. D. (2010). American Academy of Pediatrics. Clinical report‐‐sport‐ related concussion in children and adolescents. Pediatrics, 126(3), 597–615.

Hanlon, R. E., Demery, J. A., Martinovich, Z., & Kelly, J. P. (1999). Effects of acute injury characteristics on neurophysical status and vocational outcome following mild traumatic brain injury. Brain Injury, 13 (11), 873–887.

Huckans, M., Pavawalla, S., Demadura, T., Kolesaar, M., & Seelye, A., Roost N et al. (2010). A pilot study examining effects of group based cognitive strategy training treatment on self‐ reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. Journal of rehabilitation research and development, 47(1), 43‐60.

Iverson, G.L. Lange, R.T., Gaetz, M.B. & Zasler, N.D. (2013) Mild traumatic brain injury. In Brain injury medicine: Principles and practice. 2nd Edition. (N.Zasler, D. Katz, & R. Zafonte Eds. ) Demos Medical Publishing: New York,New York. 434-470

Kennedy, M. R. T., Coelho, C., Turkstra, L., Ylvisaker, M., Sohlberg, M. M., Yorkston, K., Chiou, H. H. & Kan, P. F. (2008). Intervention for executive functions after traumatic brain injury: A systematic review, meta‐analysis and clinical recommendations. Neuropsychological Rehabilitation.18: 257‐299.

Kennedy, M. R. T., Krause, M., & Turkstra, LS. (2008).  An electronic survey about college experiences after traumatic brain injury. Neurorehabilitation, 23, 511-520.

King, K. A., Hough, M. S., Walker, M. M., Rastatter, M., & Holbert, D. (2006). Mild traumatic brain injury: effects on naming in word retrieval and discourse. Brain Injury, [BI], 20(7), 725–32.

Levin HS, Diaz-Arrista R (2015) Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Lancet Neurology. 14(5): 506-17.

MacDonald, S., & Wiseman‐Hakes, C. (2010). Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive‐communication interventions. Brain Injury, 2010; 24(3), 486‐508.

MacDonald, S., & Johnson, C. J. (2005). Assessment of subtle cognitive-communication deficits following acquired brain injury: A normative study of the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES). Brain Injury, 19(11), 895–902.

Marshall, S., Bayley, M., McCullagh, S., Velikonya, D., & Berrigan, L. (2012). Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Canadian Family Physician, 58; 257‐67.

McIntyre A, janzen S, Richardson M, Kwok C., Tesell r. (2015) An overview of acquired brain injury rehabilitation randomized controlled trials. Journal of head trauma rehabilitation. [Epub ahead of print}

McKinlay, A., Grace, R., Horwood, L., Fergusson, D., Ridder, E., Macfarlane, M. (2008). Prevalence of traumatic brain injury among children, adolescents, and young adults:  Prospective evidence froma birth cohort. Brain Injury, 22(2), 175-81.

Norman R., Jaramillo, Cl, Amuan, M., Wells, M., Eapen B., & Pugh M. (2013) Traumatic brain injury in veterans of the wars in Iraq and Afghanistan:  Communication disorders stratified by severity of brain injury. Brain Injury. 27(13): 1623-1630.

Ontario Neurotrauma Foundation. Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms. Development.Norrie, J., Heitger, M., & Leatham, J. (2010). O. N. F.  Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms.

O’Neil-Pirozzi, T, Strangman G, Goldstein R., Katz D. Savage C. & Kelkar K. (2014) A controlled treatment study of internal memory strategies (I-MEMS) following traumatic brain injury. Journal of head trauma rehabilitation. 25(1): 43-51.

Perdices, M., Schultz, S., Tate, R., McDonald, S., & Togher, L. (2006). The Evidence Base of neuropsychological rehabilitation in acquired brain impairment (ABI): How good is the research. Brain Impairment, 2006, 2:119‐132.

Parrish, C., Roth, C., Roberts, B., & Davie, G. (2009). Assessment of Cognitive-Communicative Disorders of Mild Traumatic Brain Injury Sustained in Combat. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 19(2), 47–57.

Riegler, L. J., Neils-Strunjas, J., Boyce, S., Wade, S. L., & Scheifele, P. M. (2013). Cognitive intervention results in web-based videophone treatment adherence and improved cognitive scores. Medical science monitor : international medical journal of experimental and clinical research, 19, 269–75.

Ruff, R. M., Iverson, G. L., Barth, J. T., Bush, S. S., & Broshek, D. K. (2009). Recommendations for diagnosing a mild traumatic brain injury: a National Academy of Neuropsychology education paper. Archives of clinical neuropsychology the official journal of the National Academy of Neuropsychologists, 24(1), 3–10. Retrieved from

Sirmon-taylor, B., Salvatore, A. P., & Paso, E. (n.d.). Consideration of the Federal Guidelines for Academic Services for Student-Athletes with Sports-Related Concussion. Perspectives on school based issues. Asha. available at, 70–78.

Sonnenberg, L. K., Dupuis, A., & Rumney, P. G. (2010). Pre-school traumatic brain injury and its impact on social development at 8 years of age. Brain injury : [BI], 24(7-8), 1003–7.

Sroufe, N. S., Fuller, D. S., West, B. T., Singal, B. M., Warschausky, S. a, & Maio, R. F. (2010). Postconcussive symptoms & neurocognitive function after mild traumatic brain injury in children. Pediatrics, 125(6),1331–9.

Sveen, Unni; Ostensjo, Sigrid; Laxe, Sara; Soberg, H. (2013). Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups.

Tager FA, Fallon BA, Keilp J, Rissenberg M, Jones CR, LiebowitzMR (2001) A controlled study of cognitive deficits in children with chronic lyme disease. Journal of neuropsychiatry clinical neurosciences 13(4). 500‐507.

Togher L, Wiseman-Hakes C., Douglas J., Stergiou-Kita M., Ponsford J., Teasell R., Bayley M., Turkstra LS (2014) INCOG recommendations for management of cognition following traumatic brain injury, part IV: cognitive communication. Journal of head trauma rehabilitation 29(4) :353-68.

Tucker, F. M., & Hanlon, R. E. (1998). Effects of mild traumatic brain injury on narrative discourse production. Brain injury : [BI], 12(9), 783–92. Retrieved from

Vas, A, Chapman S, Spence J, Keebler M, Rodriguez-Larrain, G, Rodgers B., Jantz, T. Martinez D, Rakic J, & Krawczyk, D. (2014) Reasoning training in veteran and civilian traumatic brain injury with persistent mild impairment. Neuropsychological rehabilitation. Published online 27 May, 2015.

Walter KH, Jak AJ, Twamley EW. (2015) Psychiatric cormorbidity effects on compensatory cognitive training outcomes for veterans with traumatic brain injuries. Rehabilitation psychology. [Epub ahead of print} Accessed July 6, 2015.

Wheeler L, Nickerson S, Long K, Silver R. (2014) Expressive writing in people with traumatic brain injury and learning disability. Neurorehabilitation. 34(1): 29-37.