Recovering from a Concussion: Strategies for Treating the Whole Person

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

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

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

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

Acceleration/Deceleration

Brain moves forward in skullFrontal lobes strike inside of skullRebound contre coup injury to the occipital lobe

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

Pathophysiology

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

Neurometabolic Cascade Following Concussion/MTBI

K+

Glutamate

Glucose

Cerebral Blood Flow

Calcium

UCLA Brain Injury Research Center

(Giza & Hovda, 2001)

Mechanisms of Injury

Causes of TBI –all age groups

http://www.cdc.gov/TraumaticBrainInjury/causes.html Accessed May 30, 2013

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

Wheeled Activities


Limited Contact Activities


Non-Contact Activities


Consequences of Injury

Physical Cognitive Emotional Sleep

Headache-71%Difficulty concentrating -

57%Irritability Drowsiness

Dizziness – 55% Feeling slowed down - 58% Sadness Sleeping more

Fatigue -50% Feeling mentally “foggy” -53%

More emotional

Sleeping less

Balance problems -43%

Difficulty remembering – 43%

NervousnessTrouble falling

asleep

Visual problems -49%

Forgetful of recent events

Sensitive to light -47%

Confusion about recent events

VomitingAnswers questions more

slowly

Nausea Repeats questions

Sensitive to noise

Numbness/tingling

Dazed/Stunned

Most Common Symptoms Reported by High School Athletes

Kontos, Elbin, French Collins, Data Under Review; N = 1,438

Risk factors for protracted recovery (>3 weeks)

- 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)

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)

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!

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+

All Athletes No Previous Concussions 1 or More Previous Concussions

N=134 High School Male Football Athletes

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5

40%40%RECOVEREDRECOVERED



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

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.

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

Speech Therapy

Erin Ingvalson, MS CCC/SLP CBIS

Cognitive Rest

What is it? Is it important?How do you manage it?

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

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

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


- 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


Cognitive Activity Monitoring Log (CAM)

Gerard A. Gioia GA, PhD

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

Who evaluates for cognitive deficits in patients with TBI?

Main Players

NeuropsychologyPsychologyOccupational TherapySpeech Therapy

**A team approach is most effective

Supporting Players

PhysicianPhysical TherapyTherapeutic RecreationSocial Work

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

Why a referral to Speech-Language Pathology?

Cognitive Communication Deficit

Word finding difficultiesDifficulties with focus and

attentionDifficulties with short term

and working memoryDecreased processing

speedDifficulties with planning

and organization

Functional Deficit

Difficulties talking with family, peers, teachers

Difficulties with written language

Difficulties following directions and reading

Decrease in gradesSocial isolation

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

Standardized Assessments

Woodcock-Johnson Tests of Cognitive AbilitiesOral and Written Language ScalesClinical Evaluation of Language FundamentalsBRIEFFAVRESRivermead

**Kids can often do well on standardized tests yet still demonstrate significant functional deficits

Informal Assessments

Behavioral considerations Spontaneous discourse Patient and family complaints

Treatment of Cognitive Disorders

Education IndividualizedContext basedStrategy trainingPartner training

Occupational Therapy

Candice Gangl OTD, OTR/L


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.


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

Pt. and Family symptom interviewFunctional 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

Occupational Therapy Evaluation after Concussion

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

Vision

Treatment-VISIONRemediation

All treatment Is graded:Static to dynamicBody position changesEnvironmental 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

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

Treatment-VISION Compensation

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

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

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

OT Return to Function at Gillette

OT intervention model

Return to School: When and How

WhenBEFORE returning to sports Individualized

How504 plan/accommodationsExtended time for quizzes/tests,Breaks throughout the dayPreferential seating

Treatment-SENSORY SENSITIVITY

Skill Building:Graded introduction of stimuli, activity completion

in multiple environments with various sensory input levels

Compensation: Sunglasses, tinted glasses, earplugs, noise

canceling head phones, school accommodations, safe and comfortable space at home

Treatment-DAILY ACTIVITIES

All treatment strategies based on functional daily activity needs.

Completing the difficult activities in graded environments with use of compensation as needed

-Cooking example


Discharge Goal:Pt. is able to complete tasks independently due

to skill acquisition or with use of compensatory strategies as needed to independently and successfully get through their day.

Our goal is to graduate from therapy and be able to use what was learned to be successful each day!

Physical Therapy

Nicole LaBerge, PT ATP

Physical TherapyWhat does PT do after a brain injury?

GOAL: Assist with returning the patient to their previously tolerated physical activities, including Sports

Assess and Treat Balance, Vestibular Function, and complete the Return to Activity Protocol

Monitor patient symptoms during sessions

Physical Therapy

Common Symptoms after a mTBI:DizzinessHeadachesMotion sicknessNauseaBlurry VisionSensitivity to LightSensitivity to SoundDeconditioned/Decreased Activity ToleranceMusculoskeletal Pain (neck, back)

Physical Rest… but not forever!Physical Rest: Both feet on the ground − No physical activity− No sports− No exercise/working out− No strenuous activity− No recess− No gym class

Physical Rest… but not forever!

Physical RestRest from Sports

The body maintains balance from three systems:VisionProprioception (touch sensors in the feet, trunk, and

spine)Vestibular system (inner ear)

Sensory input from these systems is integrated and processed by the brainstem.

In response, feedback messages are sent to the eyes to help maintain steady vision and to the muscles to help maintain posture and balance.

Balance

Includes parts of the inner ear and brainProcess the sensory information involved with controlling

balance and eye movements. If injury or disease damages these processing areas,

vestibular disorders can result.

Vestibular System

DizzinessLoss of BalanceNauseaDifficulty changing positions (head and body)Car sickHeadache

Common Vestibular-Related Symptoms after Concussion

Walking – hallways, stairsSports and Recreational ActivitiesTurning Head – looking in different directionsSit to/from standingRolling over in bedLiftingGetting in/out of car

Vestibular Functional Limitations

Subjective report of symptoms Vestibular and Oculomotor AssessmentStatic and Dynamic Balance TestsCervical ROM and strengthScapular ROM and strengthResting Vitals

Physical Therapy Evaluation

All treatment is gradedFrom static to dynamicBody position changesEnvironmental challenges

Vestibular and Oculomotor ExercisesBalance exercises

BPPV assessment and treatmentManual Therapy techniquesTransition to Return to Activity (RTA)

Physical Therapy Treatment

Physical TherapyReturn to Activity Protocol

Provide education to patients/families on how to find target heart rate for each stage: Karvonen Heart Rate Formula

Stages for Return To Activity No activity and rest until asymptomatic or instructed by Provider Stage 1: Light aerobic exercise (30-40% HR) Stage 2: Sport-specific training (40-60% HR) Stage 3: Non-contact drills (60-80% HR) Stage 4: Full practice drills except contact (80-90% HR)

Patient will take final ImPACT test and if cleared by Provider, can then return to full contact activities.

Recommend THREE full practices before return to Sport

Questions?

Contact Information

David Everson, PT Rehabilitation Supervisor --Minnetonka

Clinic Gillette Children’s Specialty Healthcare Neuro Trauma Lead for Rehab Therapies [email protected]

Nicole B. LaBerge, PT, ATP Gillette Specialty Healthcare Lifetime Clinic St. Paul, MN [email protected]

Special Thank You to

Leslie Larson MS, RN, PHN, CNP- PC, CNP-PMHS, CBIS, CIC

Gillette Children’s Specialty Healthcare

---She completed some of the graphs in this presentation

• Erin E Ingvalson MS, CCC/SLP CBIS• Speech Language Pathologist• Gillette Children’s Specialty

Healthcare • St. Paul, MN• [email protected]

• Candice Gangl, OTD, OTR/L• Occupational Therapist• Gillette Lifetime Specialty Healthcare

St. Paul, MN (M-W)• Gillette Children's Specialty Healthcare

Maple Grove, MN (Th-F)• [email protected]

Resource Slides

Visual Perception: the ability to derive meaning from visual information

Visual Memory: The ability to store visual information and recall for later use

Visual Attention: the ability to focus on specific elements and use that information to complete tasks.

Vision Definitions

Visual Acuity: The clarity in which one’s eye sees (20/20)

Visual Tracking: The ability for a person to focus and follow objects in their environment.

Saccades: The quick eye movements used for scanning, tracking movements, and reading

Convergence: The ability of a person to bring eyes together to focus in on close work.

Vision Definitions

Dizziness is a sensation of lightheadedness, faintness, or unsteadiness.

Vertigo has a rotational, spinning component, and is the perception of movement, either of the self or surrounding objects.

Disequilibrium simply means unsteadiness, imbalance, or loss of equilibrium that is often accompanied by spatial disorientation.

Vestibular Definitions

Recovering from a Concussion: Strategies for Treating the Whole Person

Documents

Transcript of Recovering from a Concussion: Strategies for Treating the Whole Person