Communication and functions

cognitive in disorder
communicative cognitive
associated with trauma
cranial encephalon.

Members:

-Dominique Flandez V

Eduardo Navarro

1
 Camila Vergara

Index

Introduction 3

Epidemiology 4-5

Pathophysiology 5-7

Biomechanics of the TEC 5

Types of injuries and repercussions 5-6

Alterations in open and closed trauma 6

Tissue destruction 6-7

Evaluation and classification 7-8

Neurological clinic 8-9

Speech therapy clinic 9-12

Cognitive-communicative disorder 13-14

Discussion 14-15

Conclusion 15

Bibliography 16

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 Introduction

A traumatic brain injury in adults is defined as 'a sudden exchange

mechanical energy that causes physical and/or functional deterioration of the cranial content. It

it indicates as an alteration of the brain content, the compromise of consciousness,

post-traumatic amnesia, persistent dizziness may also exist" and it is also
one of the most important pathologies of neurological sequelae in elderly patients
productive.1

Through this report, we will present concepts related to trauma.

cranial encephalon and the alterations that can occur from brain damage
of this type, our focus will primarily be on epidemiology,
pathophysiology, neurological clinic and speech therapy clinic of this type of injury.

The aim of the report is to investigate the alterations in communication and cognition.
that occur in patients with traumatic brain injury and in which areas or
characteristics of communication we will be able to evidence more alterations or disturbances
more severe.

The importance of this research lies in the fact that throughout

our career and later our immersion in the labor field, we will be able to
to have a predefined profile of the alterations that we may find in a
patient with this type of brain alteration, keeping in mind that each patient is
a different and individual case.

1
MINISTRY OF HEALTH. Clinical guide for emergency care of trauma
Cranioencephalic. Santiago: Minsal, 2007.

3
 Epidemiology

TBI is a relevant trauma in public health not only in Chile but also in
In developed countries, traumatic brain injury is one of the leading causes of
mortality, but, in addition, a large majority is left incapacitated causing an effect
at the family, social, and economic level. The part of the population that remains incapacitated will go

increasing depending on the degree of injury, mild, severe or serious, with severe being the
which generally results in more sequelae requiring rehabilitation.

The greatest difficulty in establishing the incidence of ADHD comes from different
criteria used to define the minimum degree of severity required for
to be considered as a clinical condition and thus enter or be categorized as a TBI.

According to the Society of Neurosurgery of Chile, the cause of death from a TBI has

increased since from 4% in 1950, to reach nearly 12% in the year 2000,
considered as the third leading cause of death after cancer and diseases
cardiovascular. The percentage of death due to an accident or multiple trauma.
it is specifically 25% in TEC.

The hospitalization for a traumatic brain injury is 200 per 100,000 inhabitants for
year. Of which 50% would correspond to minor injuries (the score on the scale of
Glasgow would fall between 13-15) and 25% to moderate injuries (the score in the
Glasgow scale would be between 9-12, of which 2% to 3% becomes the
death of the patient. And the remaining percentage is of mild severe cases (the score in
the Glasgow scale would be below 8) of which 36% also
unleashes in death.2

Therefore, inferring that the rest of the people with a TBI survive, the
most part would trigger sequels and among these sequels there would be a
cognitive communication disorder.

In addition to what was mentioned above, we must consider that epidemiology does not
it is independent of social or cultural factors, a fact that becomes clear when one
they compare the statistics of different geographic areas.

Pathophysiology

2
[Rev. Med. Clin. Condes - 2006; 17(3): 98 - 105]

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Biomechanics of the TEC.

To better understand the injuries caused by TBI, an analysis will be conducted.

from the point of biomechanics. In this case, the dynamic force acts that
it corresponds to forces related to inertia along with static forces
(progressive), both react as sudden movements causing deformations
of different structures at the cephalic level, it is noteworthy that it deforms in a way
proportional the area of contact y a the energy applied.
To the mechanism of action in relation to the impact, with its contact phenomena
associates such as contusions or cranial or fractures, are added phenomena
acceleration and deceleration and the cranio-cervical-cerebral movements, of course
that although it begins at the moment of impact, it presents its clinical manifestation
later.

Types of injuries and repercussions.

A distinction must be made between the types of injuries; the primary ones are not.
controllable by the doctor, while the secondary ones would be potentially
avoidable and therefore they could be addressed early. It has been demonstrated through
studies show that ischemia is the secondary injury with the highest prevalence in the
severe head trauma case where death occurs due to the trauma, ischemia may be the cause
intracranial hypertension, reduction of cerebral pressure (perfusion) or secondary to
systemic alterations that occur in the pre-hospital phase such as hypoxia,
hypotension or anemia. On the other hand, ischemia could produce different reactions.
biochemical processes such as the release of amino acids, massive entry of calcium, production of

free radicals derived from oxygen among others, these reactions are harmful to
the cells of the nervous system and it has been proven that they are real
pathophysiological importance. These reactions that some also call
cascades, they are called tertiary injuries affecting structurally and
functionally the brain parenchyma.

5
Alterations in open and closed trauma.

In the case of a closed trauma, the language disturbance of a concussion

cerebral, is part of a confusional or subconfusional syndrome that can last
a few hours or days. Characterized by presenting episodes of adimia or verbal disfluency,
in other cases sporadic paraphasias, mutism or dysarthria. These will go
disappearing improving progressively the language. In the event of prolonging
the symptoms related to language we will be in the presence of a brain contusion
with lacerations, hemorrhagic foci, or edema in specific areas that respond to
anatomical lesions of the brain, and the symptoms will vary depending on the affected area.

Open cranioencephalic trauma will usually show us symptoms of

language and speech disorders in relation to the affected area, as well as others
symptoms of neurodynamics alterations associated with hemorrhages, hematomas or
edemas.

Tissue destruction.

When tissue destruction occurs, there would be a compression that would affect
structures associated with the language, such as the subdural hematoma and
intraparenchymal, when evacuated in a timely manner, the language alterations
they will be temporary and would return to normalcy in a few hours.

The subdural hematoma, which mainly occurs late, can be

also immediate. There is a tendency to compress the parietotemporal area and rarely
the area of the frontal lobes, the patient may also show symptoms

6
aphasia specific to the affected area, which would be referred through evacuation
surgical.

The epidural or extradural hematoma can affect the parietotemporal area, such as
result of the rupture of a branch of the middle meningeal artery, associated with
trauma. It can evolve rapidly within hours or a few days from
an initial state in which there is traumatic confusion up to an aphasia.

Evaluation and classification

The neurological exploration of patients who have suffered a TBI should include
strictly the assessment of the state of consciousness that will be measured through the
Glasgow scale, which is a general use scale, in which individuals will be evaluated.
three independent parameters: the motor response, the verbal response and the
ocular opening.

The Glasgow scale aims to avoid the interpretation of clinical observation and is based on
in an objective description of the characteristics presented by the patient. When using
An objective language reduces the margin of error and allows finding a profile.
suitable or close to those we might find in literature.

The classification of the TEC according to the Glasgow scale is as follows:

A patient will be in a coma when their final score on the scale is equal to or less than
eight points, although in general when a patient manages to open their eyes it indicates that

is out of the coma, which will allow us to differentiate the coma from a syndrome of
cloistering or other.

The TBI can also be classified according to its severity. A severe TBI is when a
patient presents a score equal to or less than 8 within the first 48 hours
having suffered the accident and after appropriate resuscitation. A moderate TEC
when a patient presents a score between 9 and 12 and finally, leaves
consider a mild TBI when the patient's score is 13, 14, or 15.3

It has been shown that the severity and duration of the decrease in the level of
consciousness is the most important isolated neurological sign in the determination of the
brain alteration4

3
Traumatic Coma Data Bank
4
[Rev. Med. Clin. Condes - 2006; 17(3): 98 - 105]

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 Neurological clinic

At the neurological clinic, we talk about classification according to neurological involvement.

This commitment is revealed according to the score given by the Glasgow scale, which measures

or evaluate eye opening, verbal response, and motor response, it is also

consider the duration of loss of consciousness and the duration of amnesia
post-traumatic, therefore the severity will be determined based on these three axes and will
classify the severity of the TBI.

The severity can be:

TBI level: the assessment in the GCS is between 13 to 15 points. Around 80% of the
patients do not include loss of consciousness and their post-traumatic amnesia is less
for an hour.

Moderate TBI: the GCS score is between 12 and 9 points. The duration of loss
The consciousness oscillates between 20 minutes to 6 hours and the post-traumatic amnesia goes

from one hour to 24 hours.

Severe TBI: the GCS score is below 8 points. The patient is

mainly unconscious and the post-traumatic amnesia that he presents is greater than 24
hours.

On a cognitive level, the possible alterations or consequences that would arise from
Presenting a TEC would be:

Motor disorders such as weakness or paralysis, ataxia, loss of fine motor skills and
thick, dysarthria, dysphagia, lack of balance, apraxia, rigidity, etc.

Sensory disorders such as visual and auditory deficits, lack of sensations

tactile and taste sensations, anosmia and agnosias.

Neuropsychological disorders (cognitive, behavioral, and emotional) such as

alterations of attention and concentration, alterations of memory and speed of
processing information, alterations in executive functions, language and speech,
emotional disorders and behavioral issues (disinhibition or exaggeration of the
experience and affective response) and alterations in perception.

Speech therapy clinic

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A patient with a head trauma will present different
alterations in communication, which may have a motor origin such as the
dysphonia or dysarthria and also a neuropsychological origin, which can coexist
mainly if the injury is diffuse or multiple.

This alteration of communication can occur at one or more levels in a

same patient, for example, in the case of a severe trauma, in the phase of
waking from a coma can involve mutism that can last for some time and that
It may later evolve into probably severe dysarthria.

Generally, the main language issues that arise are more

frequency after an injury of this type mainly occurs in pragmatics.

In the event that there is a focal lesion that compromises the language areas,
There may be issues with naming, repetition, comprehension, expression
among others.

In some cases, and as mentioned, alterations of a certain type may prevail.

inhibitory like difficulties in verbal comprehension and mutism and at other times
Alterations such as logorrhea will predominate.

When there are focal lesions in the temporal lobe, we will find alterations.
such as Wernicke's aphasia and conduction aphasia. Lesions in the frontal lobe and
prefrontal areas will trigger a transcortical aphasia or at least some.
alteration of verbal fluency. When there is a diffuse or multiple lesion in the
In the dominant hemisphere of language, we may find a patient with mixed aphasia.
the global.

The impact on cognition in patients with traumatic brain injury influences

directly about language alterations. A relationship has been described between
cognitive alterations that can affect language such as difficulties in
attention, perception, thought, memory, impulsiveness, among others, which
they influence verbal behavior.5

Speech disorders

As mentioned, in speech we can find alterations such as dysarthria,

dysprosody and apraxia, which in the acute phase may present as
5
Rehabilitation (Madr) 2002;36(6):379-387

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mutism. Generally, the speech alteration is due to an injury to the systems
subcortical engines such as the primary motor area and the cortico-bulbar tract that goes to
determine a component of spastic dysarthria. In the event that the lesion is
cerebellar dysfunction will result in ataxic dysarthria. If the damage occurs in the ganglia of
the basis the patient could present with either hypokinetic or hyperkinetic dysarthria. Also
there may be an injury in one or several motor nuclei of the cranial nerves that
they have a role in speech and in this case the patient would present with dysarthria
flaccid, in addition to presenting velopharyngeal paralysis, laryngeal paralysis, etc.

In cranial brain trauma, we can often find

mixed dysarthrias where the 5 basic motor processes will be affected.

Voice alterations

The voice may be altered when such trauma occurs in some.

parameters (intensity, tone, timbre) that may be a consequence of the condition of
dysarthria as the alteration will be at the neuromuscular level.

The speech therapy clinic for a traumatic brain injury is not easy to
determine, as it will depend on the area of the lesion, whether it is focal or diffuse and also if

it's multiple.

However, Snow and Ponsford conducted a research in 1995 in which

they relate the results of formal tests with those of the conversation analysis
spontaneous, with parameters to consider such as silences, the initiation, the lapses, the
clarifications, among others.

This study identifies difficulties mainly in:

Find the word

Logorrhea
Maintenance of the topic
Intervention shifts
Generate or maintain a conversation through questions or comments
Maintain a conversation in loud places
Understand figurative language
Repetition
Remember details of conversations
Modify tone of voice in relation to the context
Structure the speech logically and sequentially
Recognize non-verbal cues

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Snow and other researchers have studied the characteristics of patients with
cranial brain trauma (26), at 3-6 months and then at 2 years after it occurred
injury through the analysis of Damico's conversation.

In the study conducted between 3 and 6 months after the injury occurred, all patients
errors were presented in:

Insufficient information
Redundancy
Structuring of the speech
Inappropriate language for the context
Inaccuracy

In the study conducted two years after the accident, they found groups of
patients who did not improve and a group of 8 patients who underwent treatment
speech therapy for a minimum of 6 months - which worsened.

In another study conducted at the Guttmann Institute in 1998 and 1999, there were 27.
patients who had suffered a traumatic brain injury, most of them
grave. Thirteen of these patients presented with dysarthria and eight with aphasia. Some

they presented mutism at the onset of treatment (6), absence of phonation

in mechanical ventilation (1) and hearing impairment (1).

Of the patients who presented with aphasia, there were: global aphasia (1), mixed aphasia (2),

anomic aphasia (1), expressive (1) and psycholinguistic syndrome (1), which
they coexisted with cognitive and behavioral alterations, the latter being less frequent.

Of the patients who presented with dysarthria, most coexisted with alterations.
neuropsychological and behavioral disorders - more frequent than in patients
aphasics.

The presented dysarthria was of the spastic or spastic-ataxic type and the patient with
head injury and dysarthria presents alteration of posture, hypertonia,
altered phonorespiratory coordination, slow articulatory movements and alterations
of the resonance and prosody of the voice.

The pragmatic alterations present in these patients were:

Comprehensive slow down

Inappropriate tone of voice
Problems in evocation
Lack of facial expression

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 Inadequate body distance

Among others already mentioned before.6

There are differences in speech therapy clinics between one hemisphere and another:

Left hemisphere Right hemisphere

Alteration in prosody. Aphasia.

Semantic processing. Alexia.

• Speaking skills Agraphia

Alterations in pragmatics. Dysarthria.

Abandonment. Speech apraxia.

Inattention Dysphagia

Cognitive communicative disorder

Cognitive-Communicative Disorder

According to ASHA, a cognitive-communicative disorder is 'a disorder that encompasses'

difficulties in any aspect of communication due to a disruption of the

cognitive processes. Functionally, these alterations affect daily life, the
social interaction and the behavioral regulation of the person.

Cognitive alterations exist after an injury of this type that will have effects.
about the patient's behavior and also their language:

Attention: The main characteristic of a disruption in this process will be a level

low attention span, including ease of distraction and weak concentration. This
it will lead to a decrease in listening comprehension, there will be a confusing language or

inappropriate, low reading comprehension and difficulties in following objectives or

proposed instructions.

6
Communication alterations in TBI, Montserrat Martinell, Guttman Institute.

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 Perception: In this field, the perception of relevant characteristics is affected.
weakened and there is spatial disorganization, which will influence the difficulties of
patient in reading and writing, a poor understanding of facial data and of the
intonation of speech.

Memory and learning: In this area, there will be an impact on the ability and the
learning efficiency, which will cause difficulties for the follow-up of
different directions, recall problems, difficulty in reading comprehension. The
Recent and/or old information will not be integrated properly, the language will be
illogical, fragmented and lacking in order and precision.

Organization processes: There will be inadequate organization of tasks and the

time, mainly initiation, maintenance, problem resolution and
social reasoning, which will coexist with a disorganized language, scarce ability
conversational and difficulty in defining the material to study.

Reasoning: Behavior will be affected, showing impulsivity and

abstraction; the patient may be easily persuaded, will have difficulty in
discern the causes, effects, and consequences of behavior and scarcity
social reasoning.

Problem solving and decision making: The patient will exhibit impulsive traits, will use
trial and error as a strategy will have difficulties predicting the consequences of
behavior and has a superficial reasoning. Its consequence in language
there will be difficulties that the patient will present in understanding and expressing the steps

what is needed to solve a problem with a specific goal, difficulties with

the arithmetic calculation and with complex academic tasks, social behavior will be
inappropriate, lack of tact, difficulties in understanding explanations regarding the
behavior.

Discussion

After investigating the alterations of communication and cognition that are

present in patients with traumatic brain injury and knowing that the TBI in the
current situation is one of the main causes of disability in the population, due to its
sequelae and subsequent disorders associated with this TBI were clarified regarding the types of

alterations that can be triggered, these alterations lead to a decrease

in the intellectual abilities of the subject who survived the TEC, this is what

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we know or identify as sequelae, but we do not only find alteration in the
intellectual skills, but also at the motor, emotional, and behavioral levels.
removed due to this cranioencephalic trauma experienced which is located
threatening and completely affecting the integrity of the person and the environment where
is located.

In order for this integrity to be, in one way or another, 'restored', it must
it is essential to understand the patient in a multidisciplinary medical way and
in a humane way, to address the alterations that arise and thus go, little by
little, reinserting the person into the different areas that were shaken up by the
brain trauma, giving you the necessary time to complete the tasks
that help with their rehabilitation, while also integrating the patient's family into it
rehabilitation and reintegration work.

Before starting to treat the patient, rehabilitation should be set as the objective,
improve and prevent the deterioration of the function I want to address, moreover, it is necessary to

promote and develop strategies to achieve maximum functional independence of

the person.

At the phonudiological level, it becomes essential to evaluate and rehabilitate, since from a

First, we must focus on what swallowing really is. important for the
vitality and survival of the person, and later in language and communication. The
Language and communication are truly essential for achieving social reintegration,
work and help in the family relationship, and that is why we must put the most
effort as therapists in helping the patient, since in the vast majority and together
with the motivation and perseverance of the patient and their family, good results will be achieved

results.

While rehabilitation is an excellent way to help the patient, it also

we must take into account and inform our patient about the progress and that these
they may not be very quick to obtain; all these aspects we must
communicate it so that the patient and the family can start to develop their patience and to
taking a good stance on rehabilitation, and thus, in this way control a
possible frustration.

Therefore, our role will be fundamental in the intervention, rehabilitation and the
speech therapy inclusion in this type of brain injury, where we will have to be

14
trained professionals to recognize differences that are relevant in the
the individuality of each patient and will guide us to a successful therapeutic plan.

Conclusion

The head injury can trigger a wide variety of

mechanisms, this is why anyone can be affected, regardless of
gender, age or social class. This is a brain pathology of increasing importance in
Chile and in developed countries. Although many of them trigger death
who suffered from it, there is a percentage of them that survives and obtains like

neuropsychological and motor consequences, this is why it is really

importance of knowing the pathophysiology and anatomy of where it originates, as it helps us

a comprender mucho más las consecuencias ‘’especificas’’ que generara como lo son
language alterations that directly involve us regarding
our professional role and it is an area where we can intervene to obtain results
satisfactory both for the patient and personally. Also, in turn, we
will help as therapists to effectively develop an evaluation plan and
intervention and how to guide rehabilitation, although we must continue exploring and
Always keep in mind that every patient is different from another.

Bibliography

[Link] CARVAJAL-CASTRILLON; JUAN SUAREZ; ALEJANDRA ARBOLEDA,

Neuropsychological rehabilitation of hospitalized patients with trauma
subacute encephalocranial, Chilean Journal of Neuropsychology, vol. 6,
No. 2, 2011, pp. 85-90

2.E. L. GARCÍA Y GARCÍA, H. BASCUÑANA AMBRÓS and I. VILLARREAL SALCEDO,

Communication disorders due to Traumatic Brain Injury, Rehabilitation
(Madrid), 2002.

[Link] MEDINA L., ANA M. KAEMPFFER R. Epidemiological considerations

About traumas in Chile, Chilean Journal of Surgery, Vol 59 – No 3, June
2007.

4. MARÍA C. QUIJANO MARTÍNEZ, MARÍA T. CUERVO CUESTA, Alterations

cognitive after a traumatic brain injury, Pontifical University
Javeriana Cali, 2010.

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5. MINISTRY OF HEALTH. Clinical Guide for Emergency Care of Trauma
Cranioencephalic. Santiago: Ministry of Health, 2007.

6. MONTSERRAT MARTINELL,Alteraciones de la comunicación en el TCE,Instituto

Guttmann. Badalona. Spain.

7. WANDA G. WEBB, RICHARD K. ADLER, Neurología para el logopeda, 2010.

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