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Issue Editor Foreword


Challenges and Opportunities in Identification, Assessment, and Management

Section Editor(s): Constantinidou, Fofi PhD, CCC-SLP, CBIS; Issue Editor

doi: 10.1097/TLD.0000000000000191
Issue Editor Foreword

The author has indicated that she has no financial and no nonfinancial relationship to disclose.

Traumatic brain injury (TBI) results from an insult to the brain due to external physical forces and is one of the leading causes of injury, death, and disability worldwide (Maas et al., 2017). TBI is classified into three categories designated as mild, moderate, and severe, based on the severity of injury using the Glasgow Coma Score and other clinical measures assessing whether the individual was unconscious at the time of injury, the duration of impaired consciousness, the length of amnesia, the resulting cognitive, behavioral or physical disability, and subsequent recovery. This special issue is focused on survivors of concussion or mild TBI, the larger group of individuals with TBI. Although the two terms have been used interchangeably, concussion is the clinical manifestation of symptoms resulting from TBI. These include a constellation of physical, cognitive, neurobehavioral, and neurological symptoms.

TBI is an inclusive condition and does not discriminate based on ethnic or cultural boundaries. The resulting challenges while significant, they also provide opportunities for advancing rehabilitation research and interdisciplinary collaboration. In the following paragraphs, I present the challenges and opportunities and how the articles in this special issue address them.

Challenge No. 1. TBI is a high-incidence, high-burden condition. It has been estimated that globally at least 50 million people per year sustain a TBI serious enough to result in death or hospitalization. The global annual costs of TBI exceed U.S. $400 billion (Maas et al., 2017). Extensive and expensive rehabilitation is estimated to be needed in 10% of mild, 66% of moderate, and 100% of severe TBI (Coronado et al., 2011; Maas et al., 2017).

Challenge No. 2. TBI results in chronic disability. About 25% of individuals with TBI across the severity continuum cannot return to work at 1 year after injury due to memory, psychological, and other neurobehavioral deficits (Bennett, Reuter-Rice, & Laskowitz, 2016). In light of the aforementioned two challenges, O'Brien, Schellinger, Lee, Posey, and LaPlaca (2019) provide evidence on the need for more effective education programs.

Challenge No. 3. TBI is a chronic condition. TBI is no longer viewed as a single event, but a chronic condition resulting in multiple systems burden: endocrine, musculoskeletal, psychiatric, and neurological cascades. Long-term brain atrophy, altered brain connectivity is associated with lingering neurocognitive deficits in multiple linguistic–cognitive domains, years after injury (Konstantinou et al., 2016; Konstantinou, Pettemeridou, Stamatakis, Seimenis, & Constantinidou, 2019). Concussions and especially those with repeated concussions and military veterans are at a greater risk for secondary neuropsychiatric sequalae as described in Mashima et al. (2019).

Challenge No. 4. There is inadequate access to proper care due to health care disparities, variability in service delivery models, and financial restrictions within and between countries. Mild TBI presents a compounding problem due to underreporting of deficits and inefficiency in recognizing the lingering injury sequalae as addressed in Makri, Koulenti, Argyrou, Gordon, and Constantinidou (2019).

Challenge No. 5. Successful reintegration seems to be illusive. Recovery and long-term functional outcome are multidimensional phenomena, determined by critical care management, unknown genetic predisposition(s), affecting the outcome of critical pathways controlling the acute neurophysiological cascades of the injury, the personal “reserves” in terms of brain function (brain reserve) and cognitive strategies (cognitive reserve), and quality of rehabilitation efforts. Mashima et al. (2019) address reintegration strategies in their article, as they propose a patient-centered integrative approach to maximize integration.

Challenge No. 6. There is lack of accurate predictive models that can guide personalized patient management. In the case of mild TBI, the development of more sensitive neuroimaging methodologies, blood biomarkers (Myers, Lazaridis, Jermaine, Robertson, & Rusin, 2016), along with sensitive neurobehavioral measures, may be used in the future to improve our predictive accuracy of individual patient prognosis and determine who is at risk for lingering long-term deficits. The need for development of sensitive neurobehavioral measures in mild TBI is also highlighted in the Brown and Knollman-Porter (2019) article. These efforts could lead to better personalized care.

The aforementioned challenges have provided key opportunities to the medical rehabilitation and research community to tackle this chronic epidemic and could be summarized as follows:

Opportunity No. 1. Public education and evidence-based neurorehabilitation. Evidence-based reviews of neurocognitive rehabilitation indicate a significant increase in clinical trials in the past 15 years (Cicerone et al., 2019). In addition, the Centers for Disease Control and Prevention and other authorities have developed education programs for students, parents, and athletes on sports-related concussions. In their article, O'brien et al. (2019) compared knowledge about TBI and concussion in parents and students using a sample drawn from the public. They also determined whether demographic factors predicted knowledge, and compared confidence ratings with knowledge for TBI and concussion. The authors highlight that while there have been great efforts in educating the public and athletes on concussion and management, there is still misinformation and room for improvement.

Opportunity No. 2. Develop theory-driven and integrative rehabilitation programs to maximize the survivor's chances for reintegration. As Mashima et al. (2019) point out, interdisciplinary teamwork is necessary in addressing psychosocial and cognitive deficits associated with persistent postconcussion symptoms in patients with mild TBI or concussion. In their article they highlight the person-centered approach to treatment and the contribution of the rehabilitation team in validating and empathizing with the patient while providing information and empowering the patient in addressing their neurocognitive and other symptoms. In their person-centered interdisciplinary approach, the authors address the challenges faced by injured military personnel, which may include posttraumatic stress disorder and other conditions.

Opportunity No. 3. Develop systems to increase patient awareness and shift the share of responsibility to the survivor. Increased self-awareness is paramount to the individual's ability to return to preinjury independence (Constantinidou & Kennedy, 2017). Brown and Knollman-Porter (2019) implemented a multiple case study design utilizing motivational interviewing techniques in three participants with lingering cognitive–linguistic deficits. Cognitively, participants demonstrated deficits in independence, metacognition, and cognitive flexibility. Linguistically, participants demonstrated deficits in verbal memory, verbal fluency, and reading. Assessing cognitive–linguistic deficits after concussion requires both self-report and standardized measurement. Their findings also point out to the importance of metacognition and self-awareness during the assessment process to accurately identify problems and establish treatment goals.

Opportunity No. 4. Establish screening and prevention programs for vulnerable groups. Over the past 20 years there has been a proliferation screening and prevention programs focusing on vulnerable groups such as athletes and military personnel. Screening, proper identification, and multidisciplinary collaboration are key ingredients to proper management and to prevent further secondary effects as demonstrated in the Knollman-Porter et al. (2019) article. The Miami University sports concussion program, one of the oldest university-based programs in the United States, provides evidence on the characterization of concussion symptoms, including gender differences in duration of symptoms. Females required 4 more days to be symptom free as compared to men. These gender differences should be considered when monitoring athletes recovering from injury.

Opportunity No. 5. Promote international collaboration for cohort studies and for clinical research on TBI. The International Initiative on TBI Research is of significance toward international collaboration. Established in 2011, it is a joint effort between the European Commission, the Canadian Institutes of Health Research, and the National Institute of Health to advance clinical TBI research, treatment, and care (

Capturing the genetic, social–cultural characteristics of TBI survivors from around the world, combined with variability in service delivery models, enhances our ability to the effects of TBI and long-term consequences. Makri et al. (2019) in Cyprus, a small eastern Mediterranean island country, collaborated with colleagues in the United States and adapted the Brain Injury Screening Questionnaire (BISQ) in Greek to study the prevalence of concussion in elementary, secondary, and university students. Similar to findings from larger industrialized nations, the prevalence of TBI symptoms increases from 5.8% in elementary, to 9.7% in secondary, and 22.7% in university students, mostly due to sports. Validating tools like the BISQ across cultures and languages provide ammunition for international collaboration in combating this global challenge.

In closing, this special issue provides evidence on addressing key challenges from TBI. These include the implementation resulting of appropriate tools for educating the public, symptom identification and reporting, psychoeducation of the injured individual, and a team approach to the management of concussion. Rehabilitation team members and researchers are joining forces from around the globe to understand, characterize, and combat this growing epidemic.

—Fofi Constantinidou, PhD, CCC-SLP, CBIS

Issue Editor

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Bennett E. R., Reuter-Rice K., Laskowitz D. T. (2016). Genetic influences in traumatic brain injury. In Translational research in traumatic brain injury (pp. 1–32). Boca Raton, FL: CRC Press/Taylor and Francis Group.
Brown J., Knollman-Porter K. (2019). Evaluating cognitive-linguistic deficits post-concussion in adults: Contributions of self-report and standardized measures. Topics in Language Disorders, 39(3), 239–256.
Cicerone K. D., Goldin Y., Ganci K., Rosenbaum A., Wethe J. V., Langenbahn D. M., et al (2019). Evidence-based cognitive rehabilitation: Systematic review of the literature from 2009 through 2014. Archives of Physical Medicine and Rehabilitation.
Constantinidou F., Kennedy M. (2017). Traumatic brain injury in adults. In Coppens P., Papathanasiou I. (Eds.), Aphasia and related neurogenic communication disorders (2nd ed., pp. 421–450). Burlington, VT: Jones & Bartlett Publishers.
Coronado V. G., Xu L., Basavaraju S. V., McGuire L. C., Wald M. M., Faul M., et al (2011). Surveillance for traumatic brain injury-related deaths: United States, 1997-2007. Morbidity and Mortality Weekly Report: Surveillance Summaries, 60(5), 1–32.
Knollman-Porter K., Hughes M., Constantinidou F. (2019). Longitudinal trends in management and recovery patterns following sport-related concussions in college athletes. Topics in Language Disorders, 39(3), 257–275.
Konstantinou N., Pettemeridou E., Seimenis I., Eracleous E., Papacostas S. S., Papanicolaou A. C., et al (2016). Assessing the relationship between neurocognitive performance and brain volume in chronic moderate–severe traumatic brain injury. Frontiers in Neurology, 7, 29.
Konstantinou N., Pettemeridou E., Stamatakis E. A., Seimenis I., Constantinidou F. (2019). Altered resting functional connectivity is related to cognitive outcome in males with moderate-severe TBI. Frontiers in Neurology, 9, 1163.
Maas A. I., Menon D. K., Adelson P. D., Andelic N., Bell M. J., Belli A., et al (2017). Traumatic brain injury: Integrated approaches to improve prevention, clinical care, and research. The Lancet Neurology, 16(12), 987–1048.
Mashima P., Waldron-Perrine B., Ashman T., Milman L., Seagly K., Mudar R., et al (2019). Looking beyond test results: Interprofessional collaborative management of persistent mTBI symptoms. Topics in Language Disorders, 39(3), 293–312.
Makri A., Koulenti A., Argyrou K., Gordon W., Constantinidou F. (2019). The risk for TBI and persisting symptomatology in elementary, secondary, and university level students: An international perspective with the Greek version of the Brain Injury Screening Questionnaire. Topics in Language Disorders, 39(3), 276–292.
Myers R. B., Lazaridis C., Jermaine C. M., Robertson C. S., Rusin C. G. (2016). Predicting intracranial pressure and brain tissue oxygen crises in patients with severe traumatic brain injury. Critical Care Medicine, 44(9), 1754–1761.
O'Brien K. H., Schellinger K. H., Lee B., Posey R. J., LaPlaca M. C. (2019). A comparison of student and parent knowledge and perceived confidence about brain injury and concussion. Topics in Language Disorders, 39(3), 313–334.
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