KeywordsStroke; Brain Injury; Motor Deficits; Cognitive Stroke and traumatic brain injury (TBI) are leading causes of adult disability in the United States today. Of the 5.5 million people in the United States surviving stroke, 1 half live on with motor and/or cognitive impairments that affect their ability to effectively function and diminish their quality of life. In about 25% of stroke survivors, motor problems may give rise to a need for physical assistance by others. However, cognitive symptoms also affect independence, and their consequences may equal or even exceed those caused by physical limitations. 2,3 The number of people with TBI is comparable with that of stroke, with 1.4 million U.S. citizens sustaining TBI annually, and at least 5.3 million living with its disabling effects. 4,5 The most frequent unmet needs for services after TBI hospitalization are cognitive (memory and problem solving), emotional, and vocational in nature. 6Those of us who study motor and cognitive deficits in survivors of brain injury from stroke or trauma find these statistics disturbing, with our experiences leading us to suspect that even these formidable numbers underrepresent the magnitude of the problem. The reasons for this underrecognition may relate to a number of issues. One such issue is that systematic motor assessment of survivors of brain injury, like other physical diagnostic "how" skills, may take a back seat in current medical and physiatric training to learning procedures, specifics of new treatments, and other "what" treatment commodities. 7,8 We suspect that many stroke and TBI sufferers, especially in the long-term phase of recovery, may not be assessed for spasticity or even weakness. Thus, they are not identified as appropriate candidates for care to augment motor function. Similarly, many brain injury survivors may receive no evaluation or only a brief screening for cognitive dysfunction. 9 Evaluation may only assess a cognitive index, with limited sensitivity. This betrays limited appreciation for the fact that cognition is a term that applies collectively to many differentiated functional systems, from attention to mathematical skill, and a composite score such as a cognitive index is like obtaining a "sensory score" after only testing vision, which is implied to index the integrity of all senses.
