1. A Systematic Review: Knowledge and Skills Needed by a
Speech-Language Pathologist When Working with Adults
with Traumatic Brain Injury
Hanna Hintermeister, B.S., Graduate Student,
Richard K. Adler, PhD, CCC-SLP, F-ASHA
Minnesota State University Moorhead
Introduction
Methods
Results
Discussion
References
Traumatic brain injury (TBI) occurs when a force on the head causes injury to the brain. Most
TBIs are caused by motor vehicle accidents, falls, assaults, and/or explosions (Boone,
McFarlane, Berg, & Zraick, 2014). “Approximately 1.5 million brain injuries occur in the United
States annually, of the 1.5 million injured people, 80,000 people are expected to experience
persisting disability, yielding a prevalence estimate of 5.3 million Americans living with a TBI-
related disability” (Chapey, 2001, p. 880).
When a TBI occurs communication deficits can be a result affecting functional communication.
Functional communication allows an individual to express wants, needs, and feelings in a way
that others can understand.
This current study addressed the question: What knowledge and
skills do speech-language pathologists (SLPs) need when
assessing and treating a person with a TBI?
TBI severity and tools to diagnose severity
Many different tools exist to diagnose the severity of a TBI patient. Common assessment tools
include the Ranchos Los Amigos Scale, The Coma Recovery Scale-Revised, and Glasgow Coma
Scale. Functional rating scales can also be used that measures functional disability. Functional
rating scales may include the Patient Competency Rating Scale, Mayo-Portland Adaptability
Inventory, and Neurobehavioral Functioning Inventory (Chapey, 2001).
Therapy Intensity
Providing more intensive therapy on a daily basis is suggested as a way to improve therapy
outcomes (Cifu, Kreutzer, Colakowsky-Hayner, Marwitz, & Englander, 2003). Some SLPs argue
increased therapy is costly because of the additional staff needed, while others argue that added
therapy costs are necessary because increased therapy intensity improves efficiency by reducing
length of service (Cifu et al., 2003).
Reintegration
Community reintegration is significantly influenced by social competence and behavioral self-
regulation (Ylvisaker, Turkstra, & Coelho, 2003). When an SLP is involved in training of
communication partners it has been shown to have a positive effect on communication
effectiveness. This can also result in a smoother reintegration process.
Music Therapy and the SLP
A song singing program can facilitate immediate and long term changes in intonation
variability and voice range (Baker et al., 2005). Selecting songs that provide the greatest
opportunity to extend voice range should be considered (Baker et al., 2005). Introducing a
program where the range, melodic difficulty, and intervals steadily increased within a song
would be appropriate (Baker et al., 2005). Improvements in intonation can enhance the
expressivity of speech and further increase positive mood states for the patient (Baker et
al., 2005). SLPs need to be aware to observe long-term improvements rather than focus on
immediate changes in intonation, voice range, and mood (Baker et al., 2005).
A TBI can cause disabilities that affect multiple functioning domains.
Treatment approaches an SLP may implement will vary depending on the
patient. When an SLP conducts therapy with a patient with a TBI, research,
along with experience, common sense, and professional standards of care,
should help guide the development of evidence-based guidelines for
rehabilitation (Cifu et al., 2003). When considering speech, language,
cognition, voice, and executive functioning therapy techniques for a patient
with a TBI it is important to remember that each TBI patient will have their
own unique strengths and weaknesses (Ylvisaker, Jacobs, & Feeney, 2003).
The prevalence and incidence of adults with a TBI indicates the need for
SLPs to be knowledgeable and offer functional rehabilitation therapy
services.
A systematic review was utilized to gain information about the following
TBI areas and SLP involvement:
•TBI severity and tools to diagnose severity
•Therapy intensity provided by SLPs
•Reintegration into familiar settings by the patient with a TBI
•SLPs role in educating patient, family, and caregivers
•Assessment of TBI
•Collaboration between SLPs and related professionals
•Specific speech, language, and cognition area deficits
SLP’s Role in Education
Education of the family and patient is an important role of the SLP. Family education sessions,
handouts, pictures and diagrams, and one-on-one advice with the patient are all ways an SLP can
educate the family and patient (Hicks, Larkins, & Purdy, 2011).
Assessment
SLPs are encouraged to consider the World Health Organization's International Classification of
Functioning, Disability and Health (WHO-ICF) framework. This framework can be used when
selecting assessment and treatment approaches for categorizing a patient with a TBI.
Collaboration
SLPs should always collaborate with other professionals within the field who also are treating the
patient. This may include physicians, neuropsychologists, occupational therapists, physical
therapists, and nurses. Routine communication between related disciplines will assist in
establishing strengths and weaknesses and implications of the TBI.
Executive Functioning Deficits
Aspects of executive functioning include any abilities that enables a person to establish independent
and deliberate behaviors (Chapey, 2001). Examples of executive functioning behaviors or functions
may include categorization, self-awareness, reasoning, problem solving, strategic thinking, and/or
decision making (Chapey, 2001).
Social and Behavioral Disorders
Increases in challenging behavior are common after a TBI (Ylvisaker, Jacobs, & Feeney, 2003).
Two specific deficits in social and behavioral disorders that influence success for a patient with TBI
include disorientation to person, time, and/or place, and verbal and/or physical aggression (Gentry,
Smith, & Dances, 2003).
Fatigue
Fatigue is an especially commonly reported symptom of mild TBI and has been reported in 70% of
patients (Hicks et al., 2011). Incorporating fatigue management into communication interventions
for a patient with a TBI will help the patient achieve the best possible results (Hicks et al., 2011).
Treatment and management of fatigue needs a multidimensional approach including education,
restructuring, and a balance between rest and activity (Hicks et al., 2011).
Attention
Attention is reduced when therapy takes place in a noisy environment, or an environment that has a
great deal of visual stimuli (Hicks et al., 2011). Compensatory strategies such as reducing auditory
and visual stimuli by working in a quiet and plain room, and by supporting education and verbal
information with visual information helps reduce the demands of activities (Hicks et al., 2011).
Written Performance
Because young adults are the age group that most frequently experiences a TBI, these impairments
can often impact academic performance (Manasse, Hux, & Rankin-Erickson, 2000). One strategy to
minimize the impact of written performance impairments is to use a speech recognition device
(Manasee et al., 2000).
Speech Recognition
Speech recognition is the process by which a computer computes verbal speech into text. Using
speech recognition technology to produce a smaller quantity of text, but with greater ease, may be
a preferable alternative for some individuals with TBI (Manasse et al., 2000). The availability of
speech recognition technology provides an option for SLPs when trying to determine the best way
to assist a patient with a TBI (Manasse et al., 2000).
Speech Deficits
“Dysarthria may affect the speech, strength, range, timing, and accuracy of the speech movements
involved in the speech processes of respiration, phonation, nasality, articulation, and prosody
(speech rate, stress, and intonation)” (Hartelius, Theodoros, & Murdoch, 2005). Severity of speech
signs may range from mild articulation imprecision to complete unintelligibility (Hartelius et al.,
2005). Patients with a TBI may also have apraxia of speech (AOS) after their injury. “Apraxia refers
to impairment in the capacity to position muscles and to plan and sequence muscle movements for
volitional purposes” (Chapey, 2001, p. 92).
Voice Related Deficits of a TBI
Intonation in verbal speech is an additional area a patient with a TBI can show impairments (Baker,
Wigram, & Gold, 2005). Intonation helps a person convey mood, emotion, and thoughts (Baker et
al., 2005). One strategy that could help voice related deficits may include music therapy.
Baker, F., Wigram, T., & Gold, C. (2005). The effects of a song-singing programme on the
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