Full Text PA-95-034

EVALUATION, TREATMENT, AND PROGNOSIS OF THE COMMUNICATION SEQUELAE OF
TRAUMATIC BRAIN INJURY

NIH GUIDE, Volume 24, Number 7, February 24, 1995

PA NUMBER:  PA-95-034

P.T. 34

Keywords: 
  Brain 
  Injury 
  Trauma 
  Communicative Disorders, Speech 
  Pathophysiology 


National Institute on Deafness and Other Communication Disorders

PURPOSE

Approximately 50,000 of the estimated two million people who suffer
traumatic brain injury (TBI) each year in the United States have
severe persisting communication problems as a result.  Head injuries
can occur at any time in life; however, they are the primary cause of
mortality among Americans under the age of 34.  Survival rates are
particularly high for children who, along with young adults,
constitute the age group at highest risk for head injury; and, with
the increasing sophistication of early medical management, the rate
of survival continues to improve.  Although survival rates are high
among both children and adults, recent studies have questioned the
traditional belief that the prognosis for full recovery is better in
children than in adults with comparable injuries.  Little is known
about the underlying neural damage or the pathophysiology of the
speech production deficits and language disabilities commonly
associated with traumatic brain injury.  The National Institute on
Deafness and Other Communication Disorders (NIDCD) of the National
Institutes of Health (NIH) invites applications for the study of the
voice, speech, and language sequelae of traumatic brain injury, with
particular reference to pathophysiology, neuropathology, evaluation,
treatment, and prognosis.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This program
announcement, Evaluation, Treatment, and Prognosis of the
Communication Sequelae of Traumatic Brain Injury, is related to the
priority areas of diabetes and chronic disabling conditions and
special population objectives.  Potential applicants may obtain a
copy of "Healthy People 2000" (Full Report:  Stock No.
017-001-11474-0 or Summary Report:  Stock No. 017-001-11473-1)
through the Superintendent of Documents, Government Printing Office,
Washington, DC 20402-9325 (telephone 202-783-3238).

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign, for-profit and
non-profit organizations, public and private, such as universities,
colleges, hospitals, laboratories, units of state and local
governments, and eligible agencies of the Federal government.
Foreign institutions are not eligible for First Independent Research
Support and Transition (FIRST) (R29) awards.  Applications from
minority individuals, women, and individuals with disabilities are
encouraged.

MECHANISM OF SUPPORT

The support mechanisms for grants in this area will be the individual
investigator-initiated research project grant (R01) and the FIRST
(R29) award.

RESEARCH OBJECTIVES

Traumatic brain injury (TBI) is an unusual disability category in
that virtually any central nervous system function can be either
spared or impaired.  In contrast to disability categories such as
aphasia, mental retardation, or learning disability, it is difficult
to predict the strengths, weaknesses, and outcomes of individuals who
have sustained TBI.  Outcome is influenced by many factors including
pretraumatic characteristics (e.g., age, education, personality,
communication skills), nature and severity of the injury, and
posttraumatic factors (e.g., stage of recovery, medical and
rehabilitative treatment, experience following the injury, support
and emotional adjustment).

Adults with TBI are different as a group from adults with other
acquired neurogenic communication disorders such as aphasia secondary
to stroke; they  are predominantly young and their communication
profiles rarely resemble classical aphasia syndromes.  Their
characteristic cognitive and behavioral challenges, often related to
prefrontal and anterior temporal lobe structures, necessitate
modifications of transitional assessment and intervention strategies.
Furthermore, the early stages of recovery following severe TBI are
often protracted and include a relatively predictable evolution of
cognitive, communicative, and behavioral symptoms.

Children with TBI represent a unique challenge to pediatric
rehabilitation professionals and school clinicians because children
with TBI, unlike those with congenital disorders, may improve
neurologically for months or years after the injury and may recover
much of the information and skills acquired before their injury
despite substantial new learning and behavioral self-regulation
problems.  There are often delayed consequences of prefrontal injury
in young children, necessitating long-term follow-up and flexibility
in services for years after a severe injury.  In addition, the
profile of language strengths and weaknesses of children with TBI
tend to be quite unlike those of children with specific
language-learning disabilities or general developmental delay, and
the emotional issues associated with loss of function are often
different from those associated with developmental problems.
Although  the behavioral sequelae of head trauma are reportedly less
severe in children than in adults, the presence, nature, and degree
of deficits following head injury are so widely varied depending on
severity, age of onset, and even the type of outcome assessment, that
this general statement offers little in the way of meaningful
information.

Health professionals continue to be perplexed by individuals with TBI
who remain as severely speech- and language-impaired ten years after
injury as they were one year after injury.  Nor is it understood why
other individuals may show remarkable and continuing improvement even
five years after injury.  Equally puzzling are the varieties of
voice, speech, language, and swallowing disorders that are manifest
in various combinations within a given individual.  There is little
published data regarding the speech and language deficits and related
pathophysiology following traumatic brain injury.  The limited
research available identifies three areas of speech production
deficit: initiation, dyspraxia, and dysarthria.  Persistent aphonia
after mutism is reported in patients who are recovering from severe
traumatic brain injury, and documentation of the behavioral,
neuropsychological, and language sequelae of head trauma has begun.
Information gained from research in these areas, as it increases our
understanding of the communicative sequelae of traumatic brain
injury, will provide a more comprehensive framework from which to
evaluate and treat these individuals.

The NIDCD encourages both basic and clinical investigations in the
speech, language, and voice components of disorders of communication
following traumatic brain injury.  Examples of issues to be addressed
in applications submitted in response to this program announcement
include, but are not limited to, the following:

o  Development of test materials that are appropriate and sensitive
to the communication difficulties specific to the TBI population.

o  Development of standardized assessment profiles for the speech
disorders following TBI based on perceptual, acoustical, and
physiological data, which taken together will provide a firm basis
for understanding the impaired functions of respiration, phonation,
and articulation.

o  Objective assessment of the progression of disorders of the
respiratory, laryngeal, velopharyngeal, and articulatory systems, and
examination of the characteristics of speech and voice disorders
resulting from TBI.

o  Examination and comparison of the loss and redevelopment of speech
control following traumatic brain injury in the pediatric and adult
populations with particular reference to neural plasticity.

o  Examination of the role of critical age periods for speech and
language performance in relation to recovery from injury, and the
cellular and molecular mechanisms involved.

o  Multidisciplinary outcome studies that combine imaging with
detailed analysis of processes underlying language function and
reorganization.

o  Characterization of the long-term sequelae of traumatic brain
injury as manifest in speech, swallowing, voice and language
disabilities during recovery stages.

o  Development of improved therapeutic tools for rehabilitation of
communication skills in individuals with TBI.

o  Outcome studies to evaluate the effectiveness of intervention and
to track recovery of communication skills over the long term.

INCLUSION OF WOMEN AND MINORITIES RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups
and their subpopulations must be included in all NIH supported
biomedical and behavioral research projects involving human subjects,
unless a clear and compelling rationale and justification is provided
that inclusion in inappropriate with respect to the health of the
subjects or the purpose of the research.  This new policy results
from the NIH Revitalization Act of 1993 (Section 492B of Public Law
103-43) and supersedes and strengthens the previous policies
(Concerning the Inclusion of Women in Study Populations, and
Concerning the Inclusion of Minorities in Study Populations), which
have been in effect since 1990.  The new policy contains some
provisions that are substantially different from the 1990 policies.

All investigators proposing research involving human subjects should
read the "NIH Guidelines For Inclusion of Women and Minorities as
Subjects in Clinical Research," which have been published in the
Federal Register of March 28, 1994 (FR 59 14508-14513) and reprinted
in the NIH Guide for Grants and Contracts, Volume 23, Number 11,
March 18, 1994.

Investigators also may obtain copies of the policy from the program
staff listed under INQUIRIES.  Program staff may also provide
additional relevant information concerning the policy.

APPLICATION PROCEDURES

Applications are to be submitted on the grant application form PHS
398 (rev. 9/91) and will be accepted at the standard application
deadlines as indicated in the application kit.  These kits are
available from most institutional offices of sponsored research; the
Office of Grants Information, Division of Research Grants, National
Institutes of Health, Westwood Building, Room 449, Bethesda, MD
20892, telephone (301) 710-0267; and from the NIDCD Program
Administrator listed under INQUIRIES.  The title and number of the
program announcement must be typed in Section 2a on the face page of
the application.

Applications for the FIRST Award (R29) must include at least three
sealed letters of reference attached to the face page of the original
application.  FIRST Award (R29) applications submitted without the
required number of reference letters will be considered incomplete
and will be returned without review.

The completed original application and five legible copies must be
sent or delivered to:

Division of Research Grants
National Institutes of Health
6701 Rockledge Drive, MSC 7710
Bethesda, MD  20892-7710
Bethesda, MD  20817 (express mail)

REVIEW CONSIDERATIONS

Applications will be assigned on the basis of established PHS
referral guidelines.  Applications will be reviewed for scientific
and technical merit by an appropriate Initial Review Group within the
Division of Research Grants, NIH, in accordance with the standard NIH
peer review procedures.  Following scientific-technical review, the
applications will receive a second-level review by the appropriate
national advisory council.

Applications that are complete and responsive to the program
announcement will be evaluated for scientific and technical merit by
an appropriate peer review group convened in accordance with the
standard NIH peer review procedures.  As part of the initial merit
review, all applications will receive a written critique and undergo
a process in which only those applications deemed to have the highest
scientific merit, generally the top half of applications under
review, will be discussed, assigned a priority score, and receive a
second level review by the appropriate national advisory council or
board.

AWARD CRITERIA

Applications will compete for available funds with all other
applications assigned to that Institute.  The following will be
considered in making funding decisions:

o  Quality of the proposed project as determined by peer review
o  Availability of funds
o  Program priorities among research areas of the program
announcement

INQUIRIES

Written and telephone inquiries concerning this PA are encouraged.
The opportunity to clarify any issues or questions from potential
applicants is welcome.

Direct inquiries regarding programmatic issues to:

Beth Ansel, Ph.D.
Division of Human Communication
National Institute on Deafness and Other Communication Disorders
Executive Plaza South, Room 400-C
6120 Executive Boulevard MSC 7180
Bethesda, MD  20892-7180
Telephone:  (301) 402-3461
FAX:  (301) 402-6251
Email:  AnselB%NIDCD-EPS%NIH@fedtcp.ninds.nih.gov

Direct inquiries regarding fiscal matters to:

Sharon Hunt
Grants Management Officer
National Institute on Deafness and Other Communication Disorders
Executive Plaza South, Room 400-B
6120 Executive Boulevard MSC 7180
Bethesda, MD  20892-7180
Telephone:  (301) 402-0909
Email:  HuntS%NIDCD-EPS%NIH@fedtcp.ninds.nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic
Assistance No. 93.173.  Awards are made under authorization of the
Public Health Service Act, Title IV, Part A (Public Law 78-410, as
amended by Public Law 99-158, 42 USC 241 and 285) and administered
under PHS grants policies and Federal Regulations 42CFR 52 and 45 CFR
Part 74.  This program is not subject to the intergovernmental review
requirements of Executive Order 12372 or Health Systems Agency
review.

The PHS strongly encourages all grant recipients to provide a
smoke-free workplace and promote the non-use of all tobacco products.
This is consistent with the PHS mission to protect and advance the
physical and mental health of the American people.

.

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