View
2
Download
0
Category
Preview:
Citation preview
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.
Duff,M.C.,Proctor,A.,&Haley,K.(2002).Mildtraumaticbraininjury(MTBI):assessmentandtreatmentproceduresusedbyspeech-languagepathologists(SLPs).BrainInjury,16(9),773-787.
Duff,M.C.,&Stuck,S.2015.Paediatricconcussion:Knowledgeandpracticesofschool speech-language pathologists.BrainInjury,29(1),64-77.
Halstead,M.E.,McAvoy,K.,Devore,C.D.,Carl,R.,Lee,M.,&Logan,K.(2013).Returningtolearningfollowingaconcussion.AmericanAcademyofPediatrics,132(5),948-957.
Hardin,K.Y.,&Kelly,J.P.(2019).Theroleofspeech-languagepathologyinaninterdisciplinarycaremodelforpersistentsymptomatologyofmildtraumaticbraininjury.SeminarsinSpeechandLanguage,40(1),65-77.
Iverson,G.L.,Gardner,A.J.,Terry,D.P.,Ponsford,J.L.,Sills,A.K.,etal.(2017).Predictorsofclinicalrecoveryfromconcussion:asystematicreview.BritishJournalofSportsMedicine,51,941-948.
Kamins,J.,Bigler,E.,Covassin,T.,Henry,L.,Kemp,S.,Leddy,J.J.,etal.(2017).Whatisthephysiologicaltimetorecoveryafterconcussion?Asystematicreview.BritishJournalofSportsMedicine,51,935-940.
Kane,A.W.,Diaz,D.S.,Moore,C.(2019).Physicaltherapymanagementofadultswithmildtraumaticbraininjury.SeminarsinSpeechandLanguage,40(1),36-47.
Karr,J.E.,Areshenkoff,C.N.,&Garcia-Barrera,M.A.(2014).Theneuropsychologicaloutcomesof concussion: Asystematicreviewofmeta-analysesonthecognitivesequelaeofmildtraumaticbraininjury.Neuropsychology,28(3), 321-336.
ReferencesKetcham,C.J.,Bowie,M.,Buckley,T.A.,Baker,M.,Patel,K.,&Hall,E.E.(2017).Thevalueofspeech-languagepathologistsin concussionmanagement.CurrentResearch:Concussion,4(1), e8-e13.
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.
Krug,H.,&Turkstra,L.S.(2015).Assessmentofcognitive-communication disordersinadultswithmildtraumaticbraininjury.PerspectivesonNeurophysiologyandNeurogenicSpeechandLanguageDisorders,25,17-35.
Lim,K.Y.&Salvatore,A.P.(2014).Futureoftraumaticbraininjuryinadults.SeminarsinSpeechandLanguage,35(3),234-240.
TheManagementofConcussion-mild TraumaticBrainInjuryWorkingGroup.(2016).VA/DoDclinicalpracticeguidelineforthemanagementofconcussion-mild traumaticbraininjury,2.0.Accessedathttps://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf.
McCrory,P.,Meeuwisse,W.,Dvorak,J.,Aubry,M.,Bailes,J.,etal.(2017).Consensusstatementonconcussioninsport—the5th internationalconferenceonconcussion insportheldinBerlin,October2016.BritishJournalofSportsMedicine,51,838-847.
Ponsford, J.,Willmott,C.,Rothwell,A.,Cameron,P.,Ayton,G.,Nelms,R.,&Curran,C.(2001).Impactofearlyinterventiononoutcomeaftermildtraumaticbraininjuryinchildren. Pediatrics,108(6):1297–303.
ScottishIntercollegiateGuidelinesNetwork.(2009).Earlymanagementofpatientswithaheadinjury:Anationalclinicalguideline.Edinburgh,Scotland:ScottishIntercollegiateGuidelinesNetwork.
Sohlberg,M.M.,&Ledbetter,A.K.(2016)Managementofpersistentcognitivesymptomsaftersport-relatedconcussion.AmericanJournalofSpeechLanguagePathology,25(2),138-149.
Vidal,P.G.,Goodman,A.M.,Colin,A.,Leddy,J.J.,&Grady,M.F.(2012).RehabilitationStrategiesforProlongedRecoveryin PediatricandAdolescentConcussion.PediatricAnnals,41(9),1-7.
Williams-Butler,M.A.,&Cantu,R.C.(2019). Concussion practicepatternsamongspeech-language pathologists.Health,11,880-895.
Recommended