Occupational Therapy’s Role in Post Concussion Management

1. Occupational Therapy’s Role in Post Concussion Management Aimil Parmelee, MOT, OTR/L Marlaina Montgomery, MOT, OTR/L

2. Incidence • 1,300,000 individuals suffer a mild TBI each year in the U.S. • Total yearly cost is around $60 billion • 75% of all TBI are concussions • At risk groups: • Children 0 to 4 years • Older adolescents aged 15 to 19 years • Older adults aged 65+ years • Adults aged 75 years and older have the highest rates of TBI-related hospitalization

3. Definition of “Concussion” • “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” • Direct or indirect blow, impulsive force to head • Rapid onset & short duration of s/s, spontaneous resolution of s/s • Functional disturbances rather than structural • LOC is not a prerequisite • Neuroimaging • Routine neuroimaging (head CT, MRI) is recommended if there is concern for a structural injury, a focal neurological deficit, or worsening neurologic status. • Often times not indicated • CT is always normal in concussion: • inclusion criteria for mild TBI • exclusion for moderate to severe TBI

4. Symptoms of Mild TBI • Appears dazed or stunned • Confusion (unsure of game, score, or opponent) • Uncoordinated movements (stumbling) • Unable to recall words that were just spoken to them • Loss of consciousness, even if brief ( Only 10% of all concussions have a loss of consciousness) • Behavior or personality changes • Amnesia • Nausea • Headache ( most common symptom; 93%) • Balance problems or dizziness • Double vision • Pain with looking at bright light • Ringing in the ears • Feeling sluggish or slowed down • Feeling foggy or groggy • Does not “feel right”

5. Acute Concussion Symptoms vs. Post Concussion Syndrome Acute Concussion Post Concussion Syndrome Typically concussion symptoms improve in 7-10 days. When those symptoms last longer than that, it is called Post concussion syndrome (PCS). The symptoms of PCS vary from person to person and fall into 4 categories: physical difficulties, thinking and memory issues, emotional issues, and sleep issues. Often, people with PCS have not had enough physical or mental rest after injury to allow for healing. • Successful concussion recovery requires both physical and mental rest in the beginning. This is followed by a gradual return to normal activities while managing symptoms. This can be a challenge for adults with many demands at home and at work.

6. Post Concussive Personality • A • Anxious • Fearful • Labile • “Intense” • Difficulty sleeping • Difficulty concentrating • “Agitated”

7. Differential Diagnosis and Comorbid Complications • Concussion vs. Mild to Moderate TBI • Lyme’s Disease • Normal Pressure Hydrocephalus • Mental Health • Other

8. Occupational Therapy Evaluation • Past Medical History • Current Medical History • Past neurological history (migraine, seizure, CVA, prior concussions) • Current Medications • Support Structure & home environment • Work & family roles

9. Evaluation: Sport Concussion Assessment Tool • Objective measure to rank symptoms • Uses Likert scale to rate severity of symptoms • Symptom Scores ranging from 0 to 22 • Severity Score from 0 to 132

10. Evaluation: IADLS • Financial Management • Complex Home Management Tasks • Child Care • Work

11. Evaluation: Cognition Screening Tools • Montreal Cognitive Assessment (MoCA) • St. Louis University Mental Status (SLUMS) • Trails A & B • Clock Drawing • Allen Cognitive Level Screen

12. Evaluation: Cognition Focus on Functional Complaints • Look for clusters • Consider working memory, processing speed, pace, need for recheck, double check, loss of confidence • Anxiety management

13. Evaluation: Vision Subjective • Visual History • Prescription lens use • History of Eye Surgery , other conditions • Screen Time • Reading Tolerance

14. Evaluation: Vision Objective • Acuity Oculomotor • Tracking/Smooth Pursuits • Saccades • Convergence/Divergence • Normal 2-3inches • Near/Far • Visual Scanning Sheets • Brain Injury Visual Assessment Battery

15. Evaluation: Vision Objective Vestibular Screen • Vestibular Ocular Reflex (VOR) • Dynamic Visual Acuity

16. Analyzing the Environment Auditory and Visual Environment • Intensity • Amount • Competing Stimuli • Predictability

17. Intervention: Environmental Modifications • Strategies to eliminate provocative stimulus for symptom management • Sunglasses • Earplugs • Scheduled rest breaks 5-10 minutes removing self from environment • Alter Lighting • Encourage graded exposure based on symptoms resolution

18. Intervention: Adaptive Approach to Oculomotor Skills • Line blocking or Typoscope • Increasing visual contrast • Yellow acetate paper overlay to darken words • Glare Glasses or Tinted Lenses • Screen Filter • Use of “f.lux” or decreasing computer backlighting

19. Intervention: Remedial Approach to Oculomotor Skills • Fixation • Maintaining focus on target without distraction • Pursuits • Following targets: Ball around Frisbee, swinging ball, laser pointer • Mazes • Scanning sheets • Saccades • Switching targets at various distances • Switching lines, reading columns, connecting dots • Wide search/Environmental Search • Convergence • Pencil Pushups: Bringing object toward face until double image, just prior to double image holding gaze and returning to start position • Brock String: Three beads placed at various distances on string to promote visual focus on object at various distances

20. Intervention: Adaptive Approach to Cognition • Start with low tech options with good visual support • Education around fatigue and anxiety • Education on memory loop • Decrease Cognitive Load and environmental press • Paradigm Shift

21. Intervention: Remedial Approach to Cognition • Gradually increase Environmental press and task complexity • Attention Training – monitor and accommodate for visual deficits • Working on increase speed, efficiency, and timeliness of tasks

22. Intervention: Return to Work • Coverage for OT Services • Job Specific • Outline Job Tasks • Initial adaptation plan • Gradual increase over months • Highly motivated to return offers opportunities for set backs • Consider underlying cause for resisting return to work

23. Interdisciplinary Roles Physical Therapy Speech Therapy Return to Learn Cognitive Linguistic Deficits: Attention Processing Speed Memory/recall • Return to Play • Balke: Autonomic regulation • Vestibular Ocular Reflex (VOR) • Vestibular Dysfunction (Vertigo) • Dynamic Visual Acuity – Gaze stabilization

24. Recommended Referrals • Neurology • Prolonged, persistent headaches • Poor progress with inter-disciplinary rehab team • Psychology and Psychiatry • Patients presents with symptoms of depression, anxiety, and irritability • Neuro Optometrist or Ophthalmologist • Visual symptoms that last greater that 6 month post injury • Patients with history of eye surgery or pre-existing eye conditions

25. Questions

26. Reference • Clock Drawing Test. https://www.healthcare.uiowa.edu/igec/tools/cognitive/clockDrawing.pdf • Centers for Disease Control Website http//www.cdc.gov/concussion/ • Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003. • Fisher, A. G., Bray Jones, K. (2011) Assessment of Motor and Process Skills. Volume I: Development, Standardization, and Administration Manual. Seventh Edition Revised. Fort Collins, CO. Three Star Press. • Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. • Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006. • Finn, C, Waskiewicz, M. The Role of Occupational Therapy in managing post-concussion syndrome. 2015; 38 • Mangen, A. Walgermo, B, Bronnick K. Reading linear texts on paper versus computer screens. Effects on reading comprehension. Int J Educational Res. 2013; 58: 61-68

27. References • MoCA Montreal – Cognitive Asssessment. http://www.mocatest.org/ • Shulman, K. I., Gold, D. P., Cohen, C. A., Zucchero, C. A.,(1993). Clock Drawing for dementia in the community: a longitudinal study. Internaltional Journal of Psychiatry. • Sports Concussion Assessment Tool – Third Edition. http://bjsm.bmj.com/content/47/5/259.full.pdf • Suter, P, and Harvey, L. Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury; 2011. • Tariq,m S. H., Tumosa, N., Chibnall, J.T., Perry, H.M., Morley, J.E. (date). The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cogntive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) – A pilot study. Journal of American Geriatric Psychiatry. http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf • Trails A and B. http://doa.alaska.gov/dmv/akol/pdfs/uiowa_trailmaking.pdf • Unsworth, C. (1999). Cognitive and Perceptual Dysfunction: A Clinical Reasoning Approach to Evaluation and Intervention. Philadelphia, PA. F. A. Davis Company. • Zoltan, B.(2007) Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of the Adult With Acquired Brain Injury Fourth Edition. Thorofare, NJ. Slack Incorporated.