The Role of Speech-Language Pathology in an Interdisciplinary Care Model for Persistent Symptomatology of Mild Traumatic Brain Injury

Improving Cognitive Empathy Through Traumatic Brain Injury Experiential Learning: A Novel Mixed Methods Approach for Speech-Language Pathology Graduate Education

PURPOSE

The aim of this study was to gauge the impacts of cognitive empathy training experiential learning on traumatic brain injury (TBI) knowledge, awareness, confidence, and empathy in a pilot study of speech-language pathology graduate students.

METHOD

A descriptive quasi-experimental convergent parallel mixed methods design intervention pilot study (QUAL + QUANT) was conducted with a diverse convenience sample of 19 first- and second-year speech-language pathology graduate students who engaged in a half-day TBI point-of-view simulation. The simulation was co-constructed through a participatory design with those living with TBI based on Kolb's experiential learning model and followed the recommendations for point-of-view simulation ethics. After setting goals, participants engaged in four station activities completing cognitive communication activities of daily living, while experiencing manipulations to their sensory systems. Activities included reading while wearing goggles with blurred or double vision, listening with tinnitus and auditory processing disorder, and taking notes during a manipulated college lecture. Participants also interacted with an individual living with TBI and responded to targeted prompts throughout the day. Quantitative outcomes were measured using published TBI knowledge and empathy scales and analyzed with descriptive, parametric and nonparametric statistics, while qualitative data were analyzed through thematic analysis. Data were then triangulated through mixed methods. Mixed methods design quality was ensured by following the Mixed Methods Appraisal Tool (Hong et al., 2018).

RESULTS

After experiential learning, significant increases in speech-language pathologist (SLP) TBI knowledge, empathy, and awareness of TBI symptom and symptom impacts were found. Many, but not all, participants also reported changes in clinical confidence.

CONCLUSIONS

Cognitive empathy training using experiential learning appears to be a viable method to increase SLP knowledge, empathy, and symptom awareness for TBI clinical care. Future research should replicate the study with different types and locations of speech-language pathology graduate programs to consider TBI empathy training as a standard training method to improve both individual and provider outcomes.

PLAIN LANGUAGE SUMMARY

Individuals and families living with traumatic brain injury (TBI) say their providers lack necessary knowledge; do not seem to understand what living with TBI is like; and can be dismissive, uncaring, and lacking empathy. Health care providers do not automatically imagine the world from the patient's perspectives, to "walk in another's shoes"; it takes intentional effort and training. This project attempted to train those specific empathy skills for speech-language pathology graduate students through experiential learning. Experiential learning is a process where people engage in meaningful activities and spend lots of time reflecting on their experiences. Working with people living with TBI, we built a half-day workshop where 19 graduate students completed normal daily activities (such as texting, reading) through different stations that provided insights into what it may be like to have a TBI, such as wearing goggles to induce blurred or double vision, having ringing in their ears (tinnitus), and watching an overwhelming manipulated college video lecture. Afterward, participants listened to a person living with TBI and asked questions. This was important because engaging in activities without interacting with someone living with TBI misses a key idea about listening to and learning from individuals and families. We measured TBI knowledge, empathy, and confidence by looking at surveys pre- and posttraining and reading students' written reflections. Participants reported significant changes in how they think about brain injury and how they will provide clinical care for people living with TBI in the future.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28098254.

Factors Influencing Speech-Language Pathology Referral and Utilization in Mild Traumatic Brain Injury: An Exploratory Analysis

PURPOSE

Speech-language pathologists provide important services to people recovering from mild traumatic brain injury (mTBI), also called concussion, although they may be underutilized in outpatient care. Because health care providers face challenges in selecting assessments to efficiently describe patient needs, the purpose of this study was to describe factors related to patients receiving speech-language pathology services after mTBI, as well as how assessments predict amount of services received.

METHOD

In this retrospective chart review study, demographic factors, injury characteristics, and assessment scores were extracted from medical records of patients aged 14-65 years receiving services for recent (within 6 months) mTBI at an outpatient specialty clinic. The Post-Concussion Symptom Scale (PCSS), Montreal Cognitive Assessment, Standardized Assessment of Concussion, and a newly developed self-report measure of cognitive-communication function-the Cognitive-Communication Referral Indicator for Concussion (CCoRI-C)-were used as dependent variables to predict speech-language pathology service referral. For those referred, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Behavior Rating Inventory of Executive Function (BRIEF) scores were added as dependent variables predicting speech-language pathology dosage.

RESULTS

A total of 132 patient charts met inclusion and exclusion criteria. In addition to CCoRI-C and PCSS symptoms, receiving imaging, being injured in a motor vehicle crash, experiencing loss of consciousness, and being of female sex were related to speech-language pathology referrals. Of the 77 patients referred for speech-language pathology care, higher CCoRI-C, PCSS, BRIEF, RBANS total, and RBANS visuospatial scores were associated with recommended speech-language pathology dosage. Only the CCoRI-C, BRIEF-Adult Version (BRIEF-A) Behavioral Regulation, and BRIEF-A Metacognition were associated with actual number of speech-language pathology sessions attended.

CONCLUSIONS

Cognitive-communication symptoms and executive function may be important to planning speech-language pathology rehabilitative episodes of care for people with mTBI. Future work should continue to evaluate how assessments augment demographic and injury characteristics in decision making for both referral to and use of speech-language pathology services after mTBI.

Self-Perception of Cognitive-Communication Functions After Mild Traumatic Brain Injury

PURPOSE

A mixed-method approach was used to investigate the lived experiences of adults with mild traumatic brain injury (mTBI). The study aimed to understand the perceived relationship between cognitive-communication problems, thinking and communication concerns, and neurobehavioral symptoms. We hypothesized that individuals with cognitive-communication problems would attribute their problems with communication to their mTBI history and their self-perceived problems would be correlated with symptomatology.

METHOD

The Neurobehavioral Symptom Inventory (NSI) and an online cognitive-communication survey was used to conduct a study of 30 adults with mTBI history. Quantitative survey and NSI scores were analyzed with content analysis and correlational statistics.

RESULTS

The average NSI Total score was 17 with the following subscale scores: somatic (5), affective (8), and cognitive (3.9). Participants reported problems with expressive communication (56%), comprehension (80%), thinking (63%), and social skills (60%). Content analysis revealed problems in the following areas: expression (e.g., verbal, and written language), comprehension (reading and verbal comprehension), cognition (e.g., attention, memory and speed of processing, error regulation), and functional consequences (e.g., academic work, social problems, and anxiety and stress). A Pearson correlation indicated a statistically significant relationship (p < .01) between the Communication Survey Total and the Total, Somatic, Affective, and Cognitive subscales.

CONCLUSIONS

This study highlights a multifactorial basis of cognitive-communication impairment in adults with mTBI. We show that those with mTBI history perceive difficulties with cognitive-communication skills: conversations, writing, and short-term memory/attention. Furthermore, those with mTBI perceive their cognitive-communication problems after injury have impacted their vocational, social, and academic success.

American Speech-Language-Hearing Association Clinical Practice Guideline: Cognitive Rehabilitation for the Management of Cognitive Dysfunction Associated With Acquired Brain Injury

BACKGROUND

Cognitive-communication impairments following acquired brain injury (ABI) can have devastating effects on a person's ability to participate in community, social, vocational, and academic preinjury roles and responsibilities. Guidelines for evidence-based practices are needed to assist speech-language pathologists (SLPs) and other rehabilitation specialists in the delivery of cognitive rehabilitation for the adult population.

PURPOSE

The American Speech-Language-Hearing Association, in conjunction with a multidisciplinary panel of subject matter experts, developed this guideline to identify best practice recommendations for the delivery of cognitive rehabilitation to adults with cognitive dysfunction associated with ABI.

METHOD

A multidisciplinary panel identified 19 critical questions to be addressed in the guideline. Literature published between 1980 and 2020 was identified based on a set of a priori inclusion/exclusion criteria, and main findings were pooled and organized into summary of findings tables. Following the principles of the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision Framework, the panel drafted recommendations, when appropriate, based on the findings, overall quality of the evidence, balance of benefits and harms, patient preferences, resource implications, and the feasibility and acceptability of cognitive rehabilitation.

RECOMMENDATIONS

This guideline includes one overarching evidence-based recommendation that addresses the management of cognitive dysfunction following ABI and 11 subsequent recommendations focusing on cognitive rehabilitation treatment approaches, methods, and manner of delivery. In addition, this guideline includes an overarching consensus-based recommendation and seven additional consensus recommendations highlighting the role of the SLP in the screening, assessment, and treatment of adults with cognitive dysfunction associated with ABI. Future research considerations are also discussed.

Cognitive-Communication Complaints and Referrals for Speech-Language Pathology Services Following Concussion

PURPOSE

Speech-language pathologists are increasingly being recognized as key members of concussion management teams. This study investigates whether self-report of communication problems postconcussion may be useful in identifying clients who could benefit from speech-language pathology services.

METHOD

Participants included 41 adolescents and adults from an outpatient specialty concussion clinic. All completed the La Trobe Communication Questionnaire (LCQ) at admission, and 23 repeated this measure at discharge. Participants were prospectively enrolled, with chart reviews providing demographic, injury, and medical factors. The analysis considered (a) communication complaints and resolution over time, including comparison to two previously published LCQ studies of typical adults and adults with and without traumatic brain injury (TBI); (b) the relationship between communication complaints, participant factors, and common concussion assessments; and (c) factors related to speech-language pathology service referral for rehabilitation.

RESULTS

At first visit, 12 of 41 participants (29%) reported communication problems, although 19 (46%) reported difficulty with greater than half of LCQ items. At a group level, compared to published reference data of both people with chronic mixed severity TBI and controls, participants in this study reported more problems at first visit with communication overall, as well as greater difficulty with the LCQ Initiation/Conversation Flow subscale. Partner Sensitivity subscale scores at first visit were also greater than published control data. LCQ subscale scores of Initiation/Conversation Flow and Partner Sensitivity decreased from first visit to last visit, demonstrating resolution over time. Only concussion symptom scales and not demographic, injury, or cognitive screenings were related to LCQ scores. The same two LCQ subscales, Initiation/Conversation Flow and Partner Sensitivity, predicted referral for speech-language pathology services, along with symptom scales and being injured due to motor vehicle crash.

DISCUSSION

A subset of people recovering from concussion report experiencing communication problems. Reporting of particular communication problems was related to referral for speech-language pathology rehabilitation services and may be useful in directing care after concussion.

Discourse Performance in Adults With Mild Traumatic Brain Injury, Orthopedic Injuries, and Moderate to Severe Traumatic Brain Injury, and Healthy Controls

INTRODUCTION

Adults with mild traumatic brain injury (mTBI) are at risk for communication disorders, yet studies exploring cognitive-communication performance are currently lacking.

AIMS

This aim of this study was to characterize discourse-level performance by adults with mTBI on a standardized elicitation task and compare it to (a) healthy adults, (b) adults with orthopedic injuries (OIs), and (c) adults with moderate to severe TBI.

METHOD

This study used a cross-sectional design. The participants included mTBI and OI groups recruited prospectively from an emergency medicine department. Moderate to severe TBI and healthy data were acquired from TalkBank. One-way analyses of variance were used to compare mean linguistic scores.

RESULTS

Seventy participants across all groups were recruited. Groups did not differ on demographic variables. The study found significant differences in both content and productivity measures among the groups. Variables did not appear sensitive to differentiate between mTBI and OI groups.

DISCUSSION

Cognitive and language performance of adults with mTBI is a pressing clinical issue. Studies exploring language with carefully selected control groups can influence the development of sensitive measures to identify individuals with cognitive-communication deficits.

First-Line Health Care Providers' Reported Knowledge of and Referrals to Speech-Language Pathologists for Clients With Mild Traumatic Brain Injury

Purpose People with mild traumatic brain injury (mTBI) may experience deficits in cognition or communication that go unnoticed by first-line health care providers (FHPs). Speech-language pathologists (SLPs) assess and treat these domains yet are often underrepresented on mTBI multidisciplinary teams. This study's aim was to evaluate FHPs' reported knowledge of and referral practices to SLPs for individuals across the life span with mTBI. Method Physicians, physician assistants, nurse practitioners, nurses, and athletic trainers (n = 126) completed an online survey, including two Likert scale questions and one free response question relating to SLPs' role in mTBI. Results More than half of FHPs rate their knowledge of the SLP's role in mTBI management as low (somewhat knowledgeable, 29%; not very knowledgeable, 23%). Similarly, nearly two thirds of FHPs indicated rarely (19%) or never (44%), referring to SLPs for management of patients with mTBI. The majority of FHPs' open responses on the role of the SLP in mTBI management were incomplete, with many including domains that were not relevant to an SLP's role in the management of mTBI (e.g., dysphagia). Within the article, we provide results overall and according to individual profession. Conclusions Results suggest a majority of FHPs lack knowledge in the role of the SLP in the management of mTBI, which may underpin the low referral patterns reported by FHPs for SLP services. Future educational efforts for FHPs regarding the role of SLPs in mTBI care are necessary.

The Implementation of a Personalized Dynamic Approach for the Management of Prolonged Concussion Symptoms

Purpose This clinical focus article reviews the existing treatment literature on the management of prolonged concussion symptoms (PCS) for specifying treatment components that hold the most promise for effectively targeting functional goals that are disrupted due to cognitive impairments. Current evidence suggests the treatment ingredients of psychoeducation and cognitive strategy instruction can be effective for addressing changes in functioning due to perceived cognitive deficits in attention, working memory, and executive functioning. Based on the literature, we propose a personalized, dynamic approach to managing PCS that is tailored to the symptom profile of the individual client and consists of three phases, treatment setup, implementation of treatment, and discharge plan, in which the implementation phase consists of psychoeducation and strategy training. The unique aspect of this approach is the use of individualized status tracking measures on goal progress as well as strategy use and perceived strategy helpfulness to empirically guide treatment. Client performance directs clinical decisions, and the clinician adapts treatment components in order to facilitate functional change. Conclusion We provide a case example of an adolescent client treated in our university clinic to demonstrate the implementation of the proposed personalized and dynamic approach to PCS management.

Editors' Foreword: Knowledge and Skill Competencies for Speech-Language Pathology Management of Concussion

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Interprofessional Collaborative Management of Postconcussion Cognitive Symptoms

Purpose The purpose of this clinical focus article is to illustrate an interprofessional cognitive rehabilitation approach. Invited experts representing physical medicine and rehabilitation, clinical neuropsychology/rehabilitation psychology, registered nurse care coordination, and speech-language pathology share viewpoints from their discipline to engage in collaborative interventions with the goal of enhancing treatment outcomes. Conclusions Treating the multifactorial symptoms of concussion requires expertise from an interdisciplinary team (IDT) of professionals, contributing unique perspectives and providing integrative services to optimize rehabilitation outcomes for patients. Speech-language pathologists serve an important role on IDTs to deliver personalized, targeted therapies for prolonged or persistent postconcussion cognitive impairment.

Current Practices Among Speech-Language Pathologists for Mild Traumatic Brain Injury: A Mixed-Methods Modified Delphi Approach

Purpose The study purpose was to capture the clinical practice patterns of speech-language pathologists (SLPs) treating mild traumatic brain injury (mTBI; concussion). Study aims were to (a) characterize expert SLP practice patterns for the management of mTBI and (b) use qualitative content analysis to explore areas of quantitative variability within participants' responses. Method Using a modified Delphi approach, SLPs completed an online survey, with Round 1 responses shaping questions for Round 2. Round 2 results were analyzed using a concurrent partially mixed-methods approach with quantitative and qualitative items. Quantitative consensus agreement levels were set prestudy at 75% agreement or higher. Topic-level items that did not reach consensus were analyzed using qualitative content analysis. Participants SLPs engaging in a specialty mTBI-SLP networking group were invited to participate. Round 1 had nine participants (United States: 4, Canada: 5). Round 2 had 18 participants (United States: 12, Canada: 6), with a mean of 15.7 years of experience in mTBI (range: 3-33) and a mean of 7.6 clients with mTBI seen weekly (range: 1-25). Results Nearly all topic-level practice items met quantitative consensus (42/45). Consensus areas included using conceptual frameworks, interprofessional teaming, assessment and intervention practices, goal setting, and outcomes. Functional, collaborative, and client-centered care anchored clinical practice. Areas lacking consensus included SLP roles in mTBI mental and somatic health symptoms, specific measurement tools, and intervention dosages. Qualitative themes that emerged included limited interprofessional awareness for the role of SLPs in mTBI and challenges in measurement selection. Conclusions Study aims were met with clear consensus on clinical patterns implemented by SLPs specializing in mTBI. Results will inform both current clinical practices and future practice guidelines. High-level guidance and advocacy are needed to clarify SLP practice concerns and advance interprofessional education. Future work should address identified gaps, including targeted assessment tools and consensus on intervention methods.

The Cognitive-Communication Checklist for Acquired Brain Injury: A Means of Identifying, Recording, and Tracking Communication Impairments

Purpose The communication service needs of individuals with acquired brain injuries (ABIs) are frequently overlooked, leading to delays, denials, or premature discharge from communication interventions. This is particularly true for those with subtle cognitive-communication deficits, which may not be apparent until sufficiently challenged at work, in school, or in the community. The purpose of this study was to evaluate a referral tool that could promote understanding of the broad range of communication impairments that occur following ABI and lead to improved identification and referral. Method This study evaluated the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) through a survey. The CCCABI is a referral tool that summarizes 45 communication difficulties in 10 areas of cognitive-communication functioning. One hundred sixteen speech-language pathologists, 34 multidisciplinary referral sources, and 41 individuals with lived experience of brain injury were surveyed to evaluate the utility of this referral tool. Results The need for such a referral tool was endorsed by 96% of speech-language pathology respondents, 91% of multidisciplinary respondents, and 100% of respondents with lived experience of brain injury. Responses supported the CCCABI as a clear, comprehensive, and accessible tool for education and identification of the communication impairments that can occur after ABI. Conclusion The CCCABI is a means of increasing understanding of communication service needs following ABI in a manner that is accessible to individuals, families, program designers, funding sources, administrators, and multidisciplinary referral sources.

Understanding Cognitive Communication Needs in Pediatric Traumatic Brain Injury: Issues Identified at the 2020 International Cognitive-Communication Disorders Conference

Purpose In early 2020, the second International Cognitive-Communication Disorders Conference was held to provide an opportunity for researchers and clinician-scientists to discuss the most recent advances and pressing issues in the care of individuals with cognitive-communication disorders (CCDs). Presentations and discussions resulted in the identification of four areas in need of attention: (a) terminology, (b) training, (c) interdisciplinary teams, and (d) pediatrics. We will explore the four themes identified at ICCDC, specifically expanding on how terminology, training, and teams intersect in pediatric traumatic brain injury care. Additionally, we will provide two case studies to highlight the integration of these themes and suggest ways to advance clinical service provision across medical and educational settings for persons with CCDs through the lens of pediatrics. Conclusion While speech-language pathology has come a long way since the original discussion of CCD over 30 years ago, clinicians and researchers have ongoing opportunities to help advance the ways in which speech-language pathologists offer support to persons, specifically children, with CCDs and to continue to advance the profession.

Prospective Exploration of Cognitive-Communication Changes With Woodcock-Johnson IV Before and After Sport-Related Concussion

Purpose The purpose of this study was to evaluate changes in cognitive-communication performance using Woodcock-Johnson IV Tests (WJIV) from pre-injury baseline to post sport-related concussion. It was hypothesized that individual subtest performances would decrease postinjury in symptomatic individuals. Method This prospective longitudinal observational nested cohort study of collegiate athletes assessed cognitive-communicative performance at preseason baseline and postinjury. Three hundred and forty-two male and female undergraduates at high risk for sport-related concussion participated in preseason assessments, and 18 individuals met criteria post injury. WJIV subtest domains included Word Finding, Speeded Reading Comprehension, Auditory Comprehension, Verbal Working Memory, Story Retell, and Visual Processing (letter and number). The power calculation was not met, and therefore data were conservatively analyzed with descriptive statistics and a planned subgroup analysis based on symptomatology. Results Individual changes from baseline to postinjury were evaluated using differences in standard score performance. For symptomatic individuals, mean negative decreases in performance were found for Retrieval Fluency, Sentence Reading Fluency, Pattern Matchings, and all cluster scores postinjury. Individual performance declines also included decreases in story retell, verbal working memory, and visual processing. Conclusions This study identified within-subject WJIV performance decline in communication domains post sport-related concussion and reinforces that cognitive-communication dysfunction should be considered in mild traumatic brain injury. Key cognitive-communication areas included speeded naming, reading, and verbal memory, though oral comprehension was not sensitive to change. Future clinical research across diverse populations is needed to expand these preliminary findings.

Cognitive-communication performance following mild traumatic brain injury: Influence of sex, age, education, site of lesion and bilingualism

BACKGROUND

Although previous research studies have defined several prognostic factors that affect cognitive-communication performance in patients with all traumatic brain injury (TBI) severity, little is known about what variables are associated with cognitive-communication impairment in complicated mild TBI (mTBI) specifically.

AIMS

To determine which demographic and trauma-related factors are associated with cognitive-communication performance in the early recovery phase of acute care following a complicated mTBI.

METHODS & PROCEDURES

Demographic and accident-related data as well as the scores on cognitive-communication skill measures in the areas of auditory comprehension (complex ideational material subtest of the Boston Diagnostic Aphasia Examination), verbal reasoning (verbal absurdities subtest of the Detroit Test of Learning Aptitude), confrontation naming (short form of the Boston Naming Test), verbal fluency (semantic category and letter category naming), and conversational discourse (conversational checklist of the Protocole Montréal d'évaluation de la communication) were retrospectively collected from the medical records of 128 patients with complicated mTBI admitted to a tertiary care trauma hospital. Multiple linear regressions analyses were carried out on the variables sex, age, education level, Glasgow Coma Scale (GCS) score, lesion site and bilingualism.

OUTCOMES & RESULTS

Females performed better than males on letter-category naming, while those more advanced in age performed worse on most cognitive-communication measures. Patients with higher education achieved better confrontation and letter-category naming, whereas reading comprehension results were worse with a lower GCS score. Bilingual individuals presented more difficulty in conversational discourse skills than those who spoke only one language. In terms of site of lesion, the presence of a right frontal injury was associated with worse auditory and reading comprehension and an occipital lesion was related to worse confrontation naming.

CONCLUSIONS & IMPLICATIONS

Cognitive-communication skills should be evaluated early in all patients with complicated mTBI, but especially in those who are advanced in age, those with fewer years of education and those who present with lower GCS scores, in order to determine rehabilitation needs. The findings of this study will allow acute care clinicians to better understand how various demographic and injury-related factors affect cognitive-communication skills after complicated mTBI and to better nuance the interpretation of their evaluation results in order to improve clinical care. Further study is required regarding the influence of lesion location, sex and bilingualism following complicated mTBI. What this paper adds What is already known on the subject In early acute recovery studies including all severity of TBI, cognitive-communication performance was poorer in individuals with more advanced age, those with fewer years of education and with more severe TBI. It is not yet known which demographic and injury-related variables predict cognitive-communication performance after a complicated mTBI specifically. What this paper adds to existing knowledge We confirmed that age, level of education and TBI severity, as measured with the GCS score, were associated with some areas of cognitive-communication performance for a group of patients in the acute stage of recovery from a complicated mTBI. We also identified that sex, bilingualism and site of lesion were new variables that show an influence on aspects of cognitive-communication skills in this group of patients. What are the potential or actual clinical implications of this work? The findings of this study on prognostic factors in the case of complicated mTBI will help acute care clinicians to better understand evaluation results knowing the variables that can influence cognitive-communication performance and to nuance the interpretation of these results with the goal of determining rehabilitation needs and enhancing clinical care.

Profile of patients undergoing speech-language therapy in a physical and rehabilitation medicine hospital service

ABSTRACT Purpose: to analyze the profile and risk factors of patients attended by speech therapists in a hospital service of physical and rehabilitation medicine (P&RM) of the public health system. Methods: a retrospective cohort study was carried out. The variables were summarized using frequencies, proportions, and measures of central tendency. Relative risks (RR) were estimated, using the incidence ratio (IC:95%) and the bilateral Fisher's exact test. A level of significance was considered p <0.05. Results: 23,365 speech therapy activities distributed in 8,416 sessions were carried out between September 2016 to September 2018, with patients admitted to a P&RM service. The activities focused people over 60 years in the areas of swallowing (28.6%) and cognition (11.7%). Age equal to or greater than 60 years was identified as a risk factor for admission, due to cerebrovascular disease of 1.36 (95% CI: 1.24-1.49; p = 0.001), and belonging to section B of the National Health Fund (FONASA), 1.37 (95% CI: 1.29-1.46, p = 0.001). The RR for respiratory pathology was greater in the winter period: 1.63 (95% CI: 1.50-1.76; p = 0.001). Conclusion: elderly and low-income people are more likely to need speech therapy rehabilitation in the context of P&RM service.