Recovering from a Concussion: Strategies for Treating the Whole Person

1. Recovering from a Concussion: Strategies for Treating the Whole Person David Everson, PT Erin Ingvalson, CCC/SLP Candice Gangl OTD, OTR/L Nicole LaBerge PT, ATP

2. Objectives: • Define a mTBI • Understand the benefit of a multidisciplinary approach to treatment of a mTBI • Identify differences between the role and treatment goals of Speech, Physical and Occupational Therapy for patients with a mTBI • Define the differences between vision and vestibular treatment for a patient with mTBI • Identify treatment strategies and additional team support for the patient with persistent symptomology

3. Traumatic Brain Injury “Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.” http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf

4. Traumatic Brain Injury • Results in a graded set of clinical syndromes that may or may not involve loss of consciousness. • Fewer than 10% have a LOC • Resolution of the clinical and cognitive symptoms typically follows a sequential course • Typically associated with grossly normal neuroimaging studies • Acute clinical symptoms reflect a functional disturbance rather than structural injury

5. Acceleration/Deceleration Brain moves forward in skull Frontal lobes strike inside of skull Rebound contre coup injury to the occipital lobe

6. Rotational Injury • Brain rotates on axis causing stretching/tearing of axon • Stretching and tearing of blood vessels results in hematoma • Brain strikes skull causing contusion

7. Pathophysiology

8. Neurometabolic Cascade of Concussion • Cells activate pumps • Potassium ions out • Calcium ions into the cells • To move the ions back, brain increases metabolism • Calcium impairs the cells • Can’t make the energy to drive the ion pumps

9. 500 Calcium 400 K+ 300 Glucose % of normal 200 Glutamate 100 50 2 6 12 20 30 6 24 3 6 10 Cerebral Blood Flow 0 hours days minutes Neurometabolic Cascade Following Concussion/MTBI (Giza & Hovda, 2001) UCLA Brain Injury Research Center

10. Mechanisms of Injury

11. Causes of TBI –all age groups http://www.cdc.gov/TraumaticBrainInjury/causes.html Accessed May 30, 2013

12. Contact Activities Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

13. Wheeled Activities Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

14. Limited Contact Activities Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

15. Non-Contact Activities Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

16. Consequences of Injury

18. Most Common Symptoms Reported by High School Athletes Kontos, Elbin, French Collins, Data Under Review; N = 1,438

19. Learning Disabilities • History of migraines and migraine symptoms • Report of dizziness at injury • Age - the younger the longer the recovery • Gender • Repetitive concussions Risk factors for protracted recovery (>3 weeks)

20. Risk factors for protracted recovery (>3 weeks) • Brief LOC (<30 sec) not predictive of sub-acute or protracted outcomes following sports-concussion ---(Collins et al 2003) • Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery ---(Collins et al 2003) • On-Field dizziness best predictor of protracted recovery • Gender may influence concussions • (Colvin AC et all, The role of concussion history and gender in recovery from soccer-related concussion. Am J Sports Med. 2009;37(9):1699–1704)

21. Pediatric Athletes (<18) American Academy of Pediatrics (AAP) recommends “conservative” management: • NO return to play on same day • Seriously, NO return to play on same day • When in Doubt, Sit them OUT!

22. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 Individual Recovery From SportsMTBI: How Long Does it Take? 80% RECOVERED 60% RECOVERED N=134 High School Male Football Athletes 40% RECOVERED Collins et al., 2006, Neurosurgery

23. Minnesota Law • Minnesota Statute 121A.37 • Effective September 1, 2011 Minnesota State Law requires coaches and/or officials to remove youth athletes from participating in any youth athletic activity when the youth athlete exhibits signs, symptoms, or behaviors consistent with a concussion; or is suspected of sustaining a concussion. When a youth athlete is removed because of a concussion, the youth athlete may not again participate in the activity until the youth athlete: no longer exhibits signs, symptoms, or behaviors consistent with a concussion; and is evaluated by a provider trained and experienced in evaluating and managing concussions and the provider gives the youth athlete written permission to again participate in the activity. • https://www.revisor.mn.gov/laws/?id=90&year=2011&type=0

24. What are the risks of returning to activity before an injury is healed? Symptoms may last longer and become more intense. New symptoms may occur. Risk of repeat injury and risk of Second Impact Syndrome.

25. Who might you see in the recovery process? At Gillette we work as an interdisciplinary team with experts in a variety of fields to provide the best patient care and safe recovery. Team Members Include: Neurology Neurosurgery Neuropsychology Nurse Practitioners Nursing Occupational Therapy Physical Medicine and Rehabilitation Physical Therapy Physicians Psychology Psychiatry Social Work Sleep Medicine Speech Therapy

26. Speech Therapy Erin Ingvalson, MS CCC/SLP CBIS

27. Cognitive Rest • What is it? • Is it important? • How do you manage it?

28. What is Cognitive Rest? • Avoidance and/or elimination of cognitive activity that causes or exacerbates post concussive symptoms • Best thought of as a continuum (McLeod & Gioia, 2010

29. Is Cognitive Rest Important? • Research clearly documents metabolic crisis in the brain that occurs following concussion that results in reduced energy for physical and cognitive activity • Research on benefits of cognitive rest is divided and unclear

30. How Do You Manage Cognitive Rest? • Subsystem Cognitive Threshold Activity (Master, Gioia, Leddy & Grady 2012) - goal is to keep cognitive activity below the level of triggering symptoms - Child should stop cognitive activity at the point of developing the sensation of a dull pressure and prior to developing a headache

31. How Do You Manage Cognitive Rest? - After a period of cognitive rest the activity can be tried again at a lesser amount of time than the previous trial - Work up to increase endurance for cognitive activity for longer periods of time with no break and no symptoms

32. How Do You Manage Cognitive Rest? • Cognitive Activity Monitoring Log (CAM) Gerard A. Gioia GA, PhD

33. Return to Learning • Ultimate goal is to get the child back to school and normal routine as soon as possible following injury • If cognitive problems persist: - provide school accommodations as necessary - pursue additional evaluations as necessary - continue to provide education and support

34. Neuropsychology Psychology Occupational Therapy Speech Therapy **A team approach is most effective Who evaluates for cognitive deficits in patients with TBI? Main Players Supporting Players Physician Physical Therapy Therapeutic Recreation Social Work

35. What does the SLP do? • Provide evaluation, treatment and education regarding speech, language, and cognitive communication disorders associated with TBI • Cognitive communication disorders - Difficulty with language/communication as a result of impairments in general cognitive processes of attention, memory, and other executive functions

36. Word finding difficulties Difficulties with focus and attention Difficulties with short term and working memory Decreased processing speed Difficulties with planning and organization Why a referral to Speech-Language Pathology? Cognitive Communication Deficit Functional Deficit Difficulties talking with family, peers, teachers Difficulties with written language Difficulties following directions and reading Decrease in grades Social isolation

37. Assessment of Cognitive Communication Disorders • Assessment should be flexible and guided by patient factors, history, and chief complaints. • Assessment should include a combination of standardized and informal measures

38. Standardized Assessments • Woodcock-Johnson Tests of Cognitive Abilities • Oral and Written Language Scales • Clinical Evaluation of Language Fundamentals • BRIEF • FAVRES • Rivermead **Kids can often do well on standardized tests yet still demonstrate significant functional deficits

39. Informal Assessments • Behavioral considerations • Spontaneous discourse • Patient and family complaints

40. Treatment of Cognitive Disorders • Education • Individualized • Context based • Strategy training • Partner training

41. Occupational TherapyCandice Gangl OTD, OTR/L

42. Occupational Therapy What does OT do after a brain injury? • Assist with handling changes to your day-to-day life. • Provide ideas to strengthen skills and make changes to your environment. • Our goal is to help you return to school, work, and daily activities.

43. Occupational Therapy Examples of why to refer to OT: • Headaches while reading • Difficulties copying from the board • Unable to organize and complete multi-step projects • Sensitive to light, loud noises, and sensitive to getting hair washed • Forgetting to turn in/complete assignments • Continues to forget to take meds • Unable to read a recipe and bake (a previously loved task) • Easily distracted

44. Occupational Therapy Evaluation after Concussion • Pt. and Family symptom interview • Functional vision screen • If time: Standardized visual perceptual test: • Functional cognitive assessment: • Memory, attention, executive function skills • **This is not all-inclusive, testing determined on a case to case basis

45. Vision • Includes the eye, optic nerve, and many parts of the brain • Process the sensory information in a persons environment and with the brain decides what to do with that information • Vision can be affected by injury and or disease to any of these components

46. Treatment-VISIONRemediation • All treatment Is graded: • Static to dynamic • Body position changes • Environmental challenges • Tracking: following mazes, flashlight, watching the ball during practice • Saccades: HAART chart, X-sticks, naming items, copying from the board • Convergence: Pencil push-ups, cup toss, zoom-ball

47. Treatment-VISION Compensation • Light sensitivity: Sunglasses, tinted lenses, transition lenses. • Reading: colored overlays, visual highlighters, white on black, increased font, prism glasses • Note taking: slant board, location of desk, audio recording pens • Technology Use: Dark background, visual overlays, larger font, decreased brightness

48. Cognition, Cognition, Cognition • Cognitive deficits after a concussion may last longer than the concussion symptoms. • Important to access school records • Research on patients with a concussion has found that Cognitive Symptoms typically resolve within a 3-6 month time frame. * • Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of post-concussion syndrome following mild head injury. Clinical and Experimental Neuropsychology. 2001; 23 829-836 • Borg J, Holm L, Peloso PM, Cassidy JD, Carroll LJ, von Holst H, Paniak C, Yates D. Non-surgical intervention and cost for mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine. 2004; 43: 76-83

49. Executive Function Skills and OT • Executive Function domains include: • Initiation and Inhibition • Cognitive Flexibility/Shifting set • Working Memory • Planning and Organization • Self-regulation/Monitoring • Executive Dysfunction symptoms a family might note could include: • Lazy, doesn’t do anything • Saying things that are inappropriate • Repeating the same things over and over

50. OT Return to Function at Gillette • We have developed a Four-stage Return to Function protocol at Gillette. • Each stage has: 1. a different set of cognitive screeners or standardized tests 2. an overview/ goal for the stage, 3. Targeted skills the patient should demonstrate by the end of the stage 4. parent take-aways