BIANC Presents

1. BIANC Presents 2019 Webinar Series

2. BIANC Professional Conference December 6 & 7th, 2019 Mountain Area Health & Education Center Asheville, NC

3. What's Next? “Owning your Rehabilitation after Brain Injury" December 17th at 12pm

4. WEBINAR BASICS What to Expect • Audio • Questions in the "chat" box • Please put where you are listening from and if there is more than one person watching with you. • Certificates • Surveys • Email: webinar@bianc.net

5. Who are you? Poll • Individual with a brain injury • Family/friend/ally • Professional • Other

6. Dr. Michael DeCriscio, DC VRS CBIS Janine Pearson, MS, CCC-SLP Chiropractic Physician Neurocognitive Specialist Carolina Concussion & Physical Medicine Cognitive Rehabilitation Services, LLC Your Speakers

7. Cognitive Fatigue and Sleep Issues in TBI Janine Pearson, M.S., CCC-SLP Cognitive Rehabilitation Services, L.L.C. CogRehabServices@gmail.com CarolinaConcussion.com

8. Introduction • Over 20 years experience working as a Speech Pathologist with the brain injured population: Neurocognitive Specialist. • Work with all ages from infants to elderly. • Work in all settings but passionate about return to work and functional life. • Lived in Northern California for 20 years before moving to Raleigh area. • Partnered with CAROLINA CONCUSSION and Dr. DeCriscio in 2018.

9. Cognitive Fatigue • Everyone gets tired but TBI fatigue is very different. • The brain is a muscle. • Fatigue analogies: • Cog wheel – “I can feel my brain slowing down.” • The “Wall” – “Can’t think any more” Signs and Symptoms of Cognitive Fatigue – Audience examples

10. Examples of Cognitive Fatigue • Decreased response time • Increased sensitivity to light/noise • Irritability • Repeating • Decreased comprehension • Decreased physical ability • Headaches/Migraines • Change in vision/swallowing • Fatigue/Sleepiness • Increase in mistakes • Reading comprehension decreases • Tired eyes • Decreased balance • Nausea • Decreased memory • Word finding problems • Impulsivity *Symptoms are individual to each TBI survivor!!!

11. Cognitive Fatigue Scale l                            llll 1                           2 3                           4 5 “Fresh as       “Barely tired”      “Tired -but can “Tired - need              “TOO LATE”   A Daisy!”     still work.”                     a rest.” or “The Wall”

12. Where are you on the scale? l                            llll 1                           2 3                           4 5 “Fresh as      “Barely tired”    “Tired - but can “Tired - need              “TOO LATE”   A Daisy!”     still work.”                     a rest.”

13. Trevor

14. Trevor’s Signs of Fatigue Start of Therapy 9 months later Level 1: “Fresh as a Daisy” – Feel great! Level 2:    “A little tired” Voice works Swallow likely OK Can move body easily Bright eyed / Expressive face Quick responses Level 1:“Fresh as a Daisy” – Feel great! Level 2:    “A little tired” • GOAL: But not able to reach a Level 2 at start of therapy.

15. Trevor’s Signs of Fatigue Start of Therapy 9 months later Level 3:   “Tired but can still work” Voice works Decreasing speech intelligibility No blurry vision Swallow likely OK Can move body May have slower response times. Level 3:   “Tired but can still work” • Voice inconsistent (may need extra focus) • Decreased speech intelligibility • Not aware of blurry vision yet • Swallow may be inconsistent • Can move body with extra focus • Limited expressiveness • Slower response times.

16. Trevor’s Signs of Fatigue*Should be back to a level 2-3 after a rest* Start of Therapy 9 months later Level 4:  “Tired and need a rest” (“Rest” is minimum of 5-15 min. of quiet) Voice works (may need extra focus) Poor speech intelligibility May have difficulty taking deep breaths May have blurry vision Swallowing may be difficult (may need extra focus) Body movements slow down Flatter affect (little to no expressiveness on face) and “tired eyes” Slower response time. Verbal expression decreased. Yawning Level 4:  “Tired and need a rest” (“Rest” is minimum of 15-30 min. of quiet) • Voice not working (or difficult to turn on) • Poor speech intelligibility • Swallowing is difficult (more trouble managing saliva or trying to clear throat) • Not aware of blurry vision yet • Difficulty move body (gets “stuck” sometimes) • Flatter affect (little to no expressiveness on face) and “tired eyes” • Slower response time. Verbal expression decreased. • Yawning

17. Trevor’s Signs of Fatigue Level 5:   “TOO LATE” or “The Wall” • A nap or rest does not return Trevor to a Level 2-3. • Fatigue “Hangover” is real!!

18. Suggestions • Discuss and agree how to implement strategies to decrease and minimize fatigue levels. Who? What? • Create a list of personalized symptoms at each level. Use list to cue and/or review. • List of symptoms/levels can also be helpful to quantify improvements with managing fatigue. • Track fatigue levels throughout the day for a week or two to identify patterns and strategize on how to manage more efficiently.

19. Cognitive Fatigue Scale Tracking Sheet

20. Rest “Hierarchy” • 1) NAP = sleep • 2) REST (without stimuli) = No TV, No MUSIC, No PHONE/COMPUTER • 3) REST (with stimuli) = maybe tv, music, chatting, etc. • 4) Switching Tasks

21. Practice “Resting” to maximize energy! • Structured treatment session • House (unstructured) • Outing (small) • Outing (longer) • Full Day • Weekend • Travel (work/vacation)

22. Benefits of Using the Cognitive Fatigue Scale • BIG PICTURE - Able to work smarter, longer. • Takes planning skills, which when improved also improves Executive Function skills. • “Falter safely” to increase awareness and encourages carryover into everyday life (generalization.) ** Functioning between Cognitive Fatigue Levels 4-5 SLOWS DOWN TBI RECOVERY**

23. Fatigue and Sleep • Brain/body is healing when it is sleeping. • The basics are important: • Consistent bed and wake times. • Sleep routine. • Limit nap time. • Medications may be warranted, work with your doctor. • Track fatigue level before you go to bed and when you wake up. • Use data to determine if you need to change approach to sleep. • Better sleep is achieved when brain fatigue and physical fatigue are more closely matched when trying to fall asleep (i.e. brain may be fatigued but physical body is not – exercise to facilitate an equilibrium.)

24. Fatigue and Sleep • Mindfulness/Meditation before bed. • Love Your Brain Foundation – Meditation Movement Videos www.LoveYourBrain.com • Pranayama App • Headspace App

25. Return to Work Suggestions • Scaffolding approach works best so as not to overwhelm. • Each Stage of a “Return to Work Plan” often feels like a setback initially, but gets easier if managing fatigue properly using the established strategies of taking breaks to minimize fatigue. “One step forward, Two steps back.” • Before moving on to next Stage, all must be in agreement with readiness to advance to more hours (patient, doctor, family, boss.) • Don’t “Hit the Wall” and make it take longer to recover.

26. Return to Work Sample Plan • Stage 1: Mon, Wed, Fri - 4 hours/day (12 hours/week) • Continue with therapy 2-3 times per week. • Stage 2: Monday thru Friday 4 hours/day (20 hours/week) • Continue with therapy 2-3 times per week • Stage 3: Mon, Wed, Fri - 4 hours/day (32 hours/week) • Tue and Thus - 8 hours/day • Continue with therapy 1-2 times per week • Stage 4: Full time – 40 hours per week. • *Clear plan to rest in the evening when arrive home. • *Therapy check in after 2 weeks for fine tuning.

27. Final Considerations • Communication is KEY! • Caregiver’s opinions BIANC ARTICLE LINK (Page 6): http://www.bianc.net/wp-content/uploads/2018/05/May-Newsletter.pdf QUESTIONS? Contact: Janine Pearson, M.S., CCC-SLP cogrehabservices@gmail.com www.carolinaconcussion.com

28. Brain Injury Rehab & Fall Prevention

29. Brief Background: Dr. Michael S. DeCriscio, DC, VRS, CBIS • Undergraduate School: Gettysburg College (Biology) • Graduate School: New York Chiropractic College • Post-Graduate Vestibular Training: • 175-hour Vestibular Rehab Program with Board Certification. • 375-hour TBI Rehabilitation Program (Board Eligible). • Vestibular Experience: • Founder and former owner of Center for Dizziness & Balance Disorders (now Summit Health Center for Dizziness & Balance Disorders). 2010-2017. • Consultant for Wellspan Hospital Center for Dizziness and Balance Disorders. • Founder and clinician at Carolina Concussion & Physical Medicine.

32. Common Symptoms following TBI • Headache (71%) • Feeling Slowed Down (58%) • Difficulty Concentrating (57%) • Dizziness (55%) • Mental Fog (53%) • Fatigue (50%, likely much higher in our experience) • Blurred/Double Vision (49%) • Light Sensitivity (47%) • Memory Dysfunction (43%) • Balance Problems (43%)

35. What is the Vestibular System? • The vestibular system is composed of: • Central Vestibular System (Brain/Eyes) • Peripheral Vestibular System (Inner Ear) • Proprioception (Sensory input from the skin, muscles and joints) • All provide important information about position and motion of body relation to the external environment.

36. Diagnostics Used to Assess TBI Injuries VNG D2 Computerized Balance Testing

37. Balance and Head Trauma Between 30% and 65% of individuals with TBI suffer from: Dizziness Lack of Balance

38. Common Causes of Balance Problems After TBI • Problems with vision (double vision, partial loss of vision, problems with depth perception). • Inner Ear Problems (causes problems with balance, dizziness, vertigo/spinning)

39. Factors Determining Your Balance Disorder • How severe your brain injury is. • Where in your brain you were injured. • Previous history of head injuries or conditions. • Medications used to manage medical issues connected to the TBI.(example: sedatives)

40. What is Vestibular Rehabilitation • Vestibular rehabilitation is a specialized form of therapy that can target weak areas of the vestibular system and improve function through a series of customized exercises that can include, eye, head, and body movement exercises. • The result is decreased symptoms and improved tolerance to movements and balance.

41. Example of a Vestibular Rehab Exercise To the right is an example of Gaze Stabilization eye exercise that helps decreased blurred vision, dizziness, and imbalance due to an abnormal vestibular system.

42. Fall Prevention Tips • Assess your living environment and remove any trip hazards such as loose rugs, cords, clutter etc.. • Use non-slip mats in the shower, tub, kitchen, porch etc.. • Use night lights in rooms and hallways to reduce imbalance in the dark. • Install grab bars and handrails.

43. Case Study Courtney

44. Background History: 38-year old male rear-ended by another vehicle going over 50mph 2 weeks prior with no decrease in symptoms. Has had previous concussion from high school football. Symptoms: Headache, Dizziness, Tinnitus (ringing in ears), Imbalance, Blurred Vision, Cognitive Difficulty, Fatigue, Agitation/Irritability, and Neck Pain.

45. Reaction Time D2 Reaction Time: 1.62s Normal reaction time: <.8 seconds

46. VNG (Videonystagmography) Difficulty following targets moving quick (jumping back and forth), smooth pursuit (tracking); worse target moving up and down, and in dark causing dizziness.

47. Balance Poor balance with falling to his left (worse standing on foam).

48. Treatment Customized Vestibular and Cognitive Rehabilitation with goals of improving: • Visual Movements and normal VNG • Tolerance to Head and Body Movements • Balance in dark and on foam computer testing • Reaction Time to under .8s. • Normal cognitive function without fatigue

49. Courtney’s 2 Month Outcome Pre-Treatment Goals Post-TreatmentOutcomes Normal VNG without symptoms Able to move quick without dizziness. Normal Computerized Balance Testing with and without foam, in light or dark. D2 Reaction Time=<.7s with and without multi-tasking using cognition. Normal cognitive function without fatigue and without tinnitus or agitation. Visual Movements and normal VNG Tolerance to Head and Body Movements Balance in dark and on foam computer testing Reaction Time to under .8s. Normal cognitive function without fatigue

50. THANK YOU! We would like to thank BIANC and those who have taken time out of their day to learn more about concussions. For questions, please feel free to contact us as at: Carolina Concussion & Physical Medicine 120 Capcom Ave, Suite 104 Wake Forest, NC 27587 (919) 435-7396 info@carolinaconcussion.com www.carolinaconcussion.com