ManagementofConcussion/MildTraumaticBrainInjuryLAURAWILSON,PHD,CCC-SLP, CBIST

9/27/19

DisclosuresIamafull-timeemployeeatTheUniversityofTulsa

KSHAisprovidinganhonorariumformyparticipationtoday

IamaCertifiedBrainInjurySpecialistTrainerthroughtheACBIS/BIAA

Nootherfinancialornon-financialrelationshipstodisclose

LearningObjectives1. explainprogressionthroughreturn-to-activityprotocolsfollowingmildtraumaticbrain

injury

2. identifyfactorsthatplacepatientsatriskforprolongedrecoveryfollowingmildtraumaticbraininjuryrecovery

3. describetheroleoftheSLPineducation,assessment,andtreatmentduringtypicalandprolongedmildtraumaticbraininjuryrecovery

Reviewofconcussion/mTBI

Doesthetermweusematter?• Aretheyactuallydifferent?

• Communicationacrossfields

• Impactonclientandpublicperception

Concussion mTBI

Mildinjury=/=Mildeffects

RecreatedfromtheVA/DODClinicalPracticeGuidelinefortheManagementofConcussion-MildTraumaticBrainInjury;TheManagementofConcussion-mildTraumaticBrainInjuryWorkingGroup,2016

• Remember thattheseverityofinjuryislargelyclassifiedbasedoninitialpresentation,notoneffect

• Similarpresentationcanhavedifferentialfunctionalimpact

Concussion mTBI

Criteria Mild Moderate Severe

Structuralimaging

Normal Normalorabnormal

Normalorabnormal

LOC Upto30minutes 30 minutesupto24hours

24hoursormore

AOC Up to24hours >24hours >24hours

PTA 0-1 day Between 1-7days

>7days

GCS 13-15 9-12 3-8

Concussion/MildTBIbythenumbers…CAUSES• Falls

• MVA

• Sports-relatedaccidents

• Blastinjuries

• Assaults

INCIDENCE>1MILLIONPERYEAR

UNKNOWN

RecreatedfromBIAA,2016

Identificationofconcussion/mTBI

ConcussionindicatorsSIGNSOBSERVED

•Can’trecalleventspriortoorafterahitorfall•Appearsdazedorstunned•Forgetsaninstruction,isconfusedaboutanassignmentorposition,orisunsureofthegame,score,oropponent

•Movesclumsily

•Answersquestionsslowly•Losesconsciousness(evenbriefly…NOTREQUIRED!)

•Showsmood,behavior,orpersonalitychanges

SYMPTOMSREPORTED

•Headacheor“pressure”inhead•Nauseaorvomiting

•Balanceproblemsordizziness,ordoubleorblurryvision

•Botheredbylightornoise•Feelingsluggish,hazy,foggy,orgroggy•Confusion,orconcentrationormemoryproblems

•Justnot“feelingright,”or“feelingdown”

CDCHeadsUp,2019

Seekadditionalmedicalcareif…◦ GCS<15atinitialassessment◦ post-traumaticseizure(generalizedorfocal)◦ focalneurological signsofaskullfracture◦ lossofconsciousness◦ severeandpersistentheadache◦ repeatedvomiting (twoormoreoccasions)◦ post-traumaticamnesia>5minutes◦ retrogradeamnesia>30minutes◦ high riskmechanismofinjury (roadtrafficaccident,significantfall)◦ coagulopathy,whetherdrug-induced orotherwise.

SIGN,2009

DiagnosisConcussionremainsaCLINICALdiagnosis.

Generally,assessmentwillconsiderfactorssuchascognition(orientation,attention,memory),vestibulo-ocularfunction,andsymptoms.

Thesecanincludesideline/bedsidemeasures,ormoreextensiveneurocognitivetestingthatcomparestonormsortopatient’sownbaseline.

Managementoftypicalconcussion/mTBI

Generalprinciples forearlyconcussionmanagement

•Brief periodofcognitiveandphysicalrest

•Advancingactivityslowlyandsystematically

•Serialassessmentofsymptoms• Withsymptommonitoringbeforeandduringincreaseinactivity(avoidingsymptomexacerbation)

PhysicalandcognitiverestToavoidcatastrophicre-injury

Toavoidplacingincreaseddemandsonasystemthatneedstoheal/restoremetabolicbalance

Toavoidsymptomexacerbation

Tominimizesymptomduration?

Currentrecommendation:

BRIEFphysicalandcognitiverestduringacutetimeperiod(24-48hours)postconcussion.

Banks&Salvatore,2019

SymptomChecklistsSeveralsimilar versions

Rateonascale from0-6(none-severe)

CoverPhysical,Cognitive,Sleep,andPsychological/Emotional components

SumtomakeaTotalSymptomScore

McCroryetal.,2016

EducationandcounselingEducationandcounseling◦ BasicsofamildTBI◦ Warningsigns◦ Expectedsymptomsandtrajectory(includingemphasizinglikelihoodoffullrecovery)◦ Managementofcognitiveandphysicalactivity/rest◦ Returntoactivityplan◦ Clinicalmanagementplan(androleofotherteammembers)

Evenbriefinterventionscanimproverecovery(especiallyasmeasuredbysymptomduration)◦ Informationalbookletforkids;Ponsford,2011◦ Telephonecounseling/educationforadults;Belletal.,2008◦ Exampleresource fromCDC

Brownetal.,2014

Graduatedreturntoactivity

Importance ofaninterdisciplinary team

ConcussionsubtypesUPMC

http://rethinkconcussions.upmc.com/2016/10/concussion-clinical-trajectories/

OverlapinsymptomsConcussion Stress Anxiety Depression PTSD

Headaches X X X X X

Drowsiness X X X X X

Irritability X X X X X

Depression X X X X X

Poormemory X X X X X

Attention/Concentration X X X X X

Fatigue X X X X X

Poorsleep X X X X X

Nausea X X X X X

Worry X X X X

Dizziness/Loss ofbalance X X

Impaired hearing X X

Blurredvision X

BIAA,2016

“WhatdoesanSLPhavetodowithconcussion?”

RolesoftheSLP◦ Educationandcounseling◦ Monitoring recoveryandguiding return toactivity◦ Recommendingenvironmentalmodifications/work andschool-basedadjustments◦ Assessmentandtreatmentforindividuals withpersistentconcerns◦ Amodelofincreasedinvolvement inearlymanagement,especiallyincollegiateenvironment

Brownetal.,2014

Returntoschool/work

Totalrest

Lightmentalactivity

Part-timeschool/work(withmaximalaccommodations)

Part-timeschool/work(withmoderateaccommodations)

Full-timeschool/work(withminimalaccommodations)

Full-timeschool/work(withoutaccommodations)

Halstead,2013

SymptommanagementAvoidingsymptomexacerbation

Reduceimpairment/increaseparticipation

Maximizefunctioningonpatient-centeredgoals

Environmentalmodifications/Workandschool-basedadjustments

Shouldbesymptom-specific

Shouldbere-evaluatedasrecoverycontinues

Note:Thesemayrequirespecificeducationregardingwhen/howtoimplement

Schoolresource

Workresource

Symptom Sample adjustmentHeadache Reduction ofaggravating

stimuli(e.g.,working inquieterordarkerspace,reducedscreentime)

Difficultyconcentrating ExtratimefortasksPrioritizationofactivities

Difficulty remembering Written notesfrommeetings

Fatigue Frequentbreaks,considermentalexertion

Returntoplay

Symptom-limitedactivity

Lightaerobicexercise

Sportspecificexercise

Non-contacttraining

Fullcontactpractice

Return toplay

McCroryetal.,2016

Recoveryin7-10days?Factorstoconsider(Iversonetal.,2017)

• Age

• Sex/gender

• Earlyinjuryburden(i.e.,symptomsandcognition)

• Premorbidmentalhealthconcerns(e.g.,depression,substanceabuse)

• Litigation(Karretal.,2014)

• Previousconcussions(?)

• ADHD/learningdisabilities (?)

• Migrainehistory(?)

Majoritywithclinicalrecoverywithin1month◦ Notethatthisdoesnotnecessarilycorrespondwithreturntophysiologicalbaseline(Kaminsetal.,2017;Limetal.,2019)

PersistentsymptomsfollowingconcussionOftenconsideredpersistentat3months

Somemovementawayfromterm“post-concussivesyndrome”

Mayberelatedtobrainchanges?

Attentionandmemoryissuesmostcommoncognitivesymptoms,butcanbeaccompaniedbyothersomaticandpsychologicalsymptoms

”Goodolddays”bias?

Sohlberg &Ledbetter,2016

SLProle:persistentcognitivesymptomsPRACTICEPATTERNS

SLPpracticepatterns2002studyofSLPsinNCandILworkingwithindividualswithmTBI(Duff,Proctor,&Haley,2002)◦ Surveyed thoseinnon-school settings◦ FoundSLPsfelttheylackedtheskillneeded forappropriatecounseling◦ Manywereusing inappropriateassessmenttools(e.g.,aphasiatests)andmanywerenotaddressingcommoncognitivedeficits

2015studyofschoolSLPs(DuffandStuck,2015)◦ Found SLPshadinaccurateknowledgeaboutconcussion, wereunfamiliarwithconcussion-related terminology◦ Onlyaminority ofSLPsreportedworkingwithindividuals withconcussion◦ Manywereusinginappropriateassessment tools andnotaddressing cognitivedeficits

Currentpracticepatterns2019studyofSLPsworkinginout-patientclinics(Williams-Butler&Cantu,2019)◦ Identified fromSIG2◦ Allincludedpatienteducation◦ Problemspersistwithselectionofdiagnostic tools◦ Screeners(e.g.,RBANS)◦ Language-focusedassessment tools(e.g.,BDAE)

◦ Mostcommon focusofintervention◦ Attentionbuilding◦ Executivefunctionbuilding◦ Return-to-workaccommodations

SLProle:persistentcognitivesymptomsASSESSMENT

AssessmentGoalistodeterminefunctionalimpactandsetplanforrehabilitation(Hardin&Kelly,2019)

Includebothself-reportandfunctional,performance-basedmeasures

Considerefforttesting

TwohelpfularticlestodrivetoolselectionforSLPs:◦ Hardin&Kelly,2019◦ Krug&Turkstra,2015

Teammembers/referralsAthleticTrainer

Audiology/Vestibular

OccupationalTherapy

Optometry/Ophthalmology

PhysicalTherapy

Physicians

Psychology/Neuropsychology

SpecialEducators

Kane,Diaz,&Moore,2019;Vidaletal.,2012;Ketchametal.,2017;TheManagementofConcussion-mildTraumaticBrainInjuryWorkingGroup,2016

SLProle:persistentcognitivesymptomsTREATMENT

Generalmanagement•Educatingpatientsregardingbreakdowns

•Identifyingbarriersandwaystocompensate

•Promotinggeneralizationofstrategiesandskills

•Consideringotherfactorsthatmightimpactcognition

•Expectingshort-termtherapy

Cornis-Popetal.,2012

Evidence-based interventionsEducation

Environmentalmodifications

Metacognitivestrategytraining

Directattentiontraining

Compensatorystrategiesformemory(internalandexternal)

Assistivetechnologytraining

Buildingcognitiveendurance

Cornis-Pop etal.,2012;Sohlberg &Ledbetter,2016

EndingtreatmentWhenpatientshavereturnedtobaseline

Whenpatientshavegeneralizedstrategiestosupportsuccessfulparticipation

Whenpatientsneedtoprioritizeotherinterventions

Whenaplanisestablishedtore-engageifachangeinsituationoccurs

MiamiUniversityConcussionManagementProgram:anexpanded rolefortheSLPPrimarymembersoftheteam:◦ AT◦ SLP◦ TeamPhysician◦ Athlete

KnollmanPorter,Constantinidou, &HutchinsonMarrona,2014;Knollman-Porter, Constantinidou, Beardslee,&Dailey,2019

SLPinvolvedinthefollowing:◦ Education(preandpostinjury)◦ Baselineneurocognitive andsymptomassessment◦ COWAT,GroovedPegboard,King-Devick, BESS,ImPACT,PCRS

◦ Postconcussionneurocognitive andsymptomassessment(within~2days)

◦ Academicaccommodations, recommendations,andstrategies(including sharinginformationwithfaculty)

◦ Rehabilitation

ReferencesBanks,R.E.,&Salvatore,A.P.(2019).Concussions: Activityavoidanceandrestrecommendation.SeminarsinSpeechandLanguage,40(1),27-35.

Bell,K.R.,Hoffman, J.M.,Temkin,N.R.,Powell,J.M.,Fraser,R.T.,etal.(2008).Theeffectoftelephonecounsellingonreducingpost-traumaticsymptoms aftermildtraumaticbraininjury:arandomisedtrial.JournalofNeurology,Neurosurgery,andPsychiatry,79(11),1275-1281.

Brown,J.,O’Brien,K.,Knollman-Porter,K.,&Wallace,T.(2019).Thespeech-language pathologists’roleinmildtraumaticbraininjuryformiddleandhighschool-agechildren:viewpointsonguidelinesfromthecentersfordiseasecontrolandprevention.AmericanJournalofSpeech-Language Pathology,28,1363-1370.

CentersforDiseaseControl.HeadsUp.Accessedathttps://www.cdc.gov/headsup/index.html onAugust30,2019.

Cornis-Pop,M.,Mashima,P.A.,Roth,C.R.,Maclennan, D.L.,Picon,L.M.,etal.(2012).Cognitive-communication rehabilitationforcombat-relatedmildtraumaticbraininjury.JournalofRehabilitationResearch&Development,49(7),11-31.

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Karr,J.E.,Areshenkoff,C.N.,&Garcia-Barrera,M.A.(2014).Theneuropsychologicaloutcomesof concussion: Asystematicreviewofmeta-analysesonthecognitivesequelaeofmildtraumaticbraininjury.Neuropsychology,28(3), 321-336.

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Knollman-Porter, K.,Constantinidou,F.,Beardslee,J.,&Dailey,S.(2019).Multidisciplinarymanagementofcollegiatesports-relatedconcussions.SeminarsinSpeechandLanguage,40(1),3-12.

Knollman Porter,K.,Constantinidou,F.,&HutchinsonMarron,K.(2014).Speech-languagepathologyandconcussion managementinintercollegiateathletics:theMiamiuniversityconcussionmanagementprogram.AmericanJournalofSpeech-Language Pathology,23,507-519.

Kolakowsky-Hayner,S.A.,Reyst,H.,&Abashian,M.C.(Eds.)(2016).TheEssentialBrainInjuryGuide,5th Ed.Vienna,VA:BrainInjuryAssociationofAmerica.

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