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Individualized�Management�and�Treatment�Following�Traumatic�Brain�Injury
Jami�Skarda,�M.S.,�CCCͲSLPWarrior�Recovery�Center,�Fort�Carson,�CO
Disclaimer
The�views�expressed�in�this�presentation�are�those�of�the�author�and�do�not�necessarily�reflect�the�official�policy�or�position�of�the�United�States�Government�or�the�Department�of�Defense.��
This�presentation�does�not�endorse�any�particular�manufacturer�or�product.��
I�am�receiving�an�honorarium�for�this�presentation.�
Outline
• Overview�of�Concussion�and�Traumatic�Brain�Injury
• Symptoms�of�Traumatic�Brain�Injury�and�Concussion
• Screening�Tools• Assessment• Return�to�Activity• Treatment
Learning�Objectives• Identify�signs�and�symptoms�of�concussion�and�traumatic�brain�injury
• Explain�the�return�to�activity�guidelines• Identify�cognitiveͲcommunication�deficits�associated�with�concussion�and�traumatic�brain�injury
• Apply�treatment�techniques�for�cognitiveͲcommunication�deficits
• Recognize�his/her�role�in�educating�others�regarding�concussion�and�traumatic�brain�injury
2
“Sometimes�I�feel�lost�in�a�storm,�waiting�for�a�break�in�the�clouds…”
DefinitionA�traumatically�induced�structural�injury�and/or�physiological�disruption�of�brain�function�as�a�result�of�external�force�that�is�indicated�by�new�onset�or�worsening�of�at�least�one�of�the�following�clinical�signs,�immediately�following�the�event:�• Loss�of�consciousness�(LOC)• PostͲtraumatic�amnesia�(PTA)• Alteration�of�Consciousness�(AOC)• Neurological�deficits�that�may�or�may�not�be�temporary
• Intracranial�lesion
www.dvbic.dcoe.mil (2010)
Classification
• Concussion/Mild�TBI�– Confusion/Disorientation�<24�hours– LOC�up�to�30�minutes– Memory�loss�<24�hours– Imaging�yields�normal�results
• Moderate�TBI– Confusion/Disorientation�>24�hours– LOC�more�than�30�minutes– Memory�loss�>24�hours�but�<7�days– Imaging�yields�normal�or�abnormal�results
Defense�and�Veterans�Brain�Injury�Center�(2014)
Classification
• Severe�TBI�– Confusion/Disorientation�>24�hours– LOC�>24�hours–Memory�loss�>7�days– Imaging�yield�normal/abnormal�results
• Penetrating�TBI– Dura�mater�is�penetrated– Caused�by�high�or�low�velocity�projectiles�or�objects
Defense�and�Veterans�Brain�Injury�Center�(2014)
3
Severity�Determination
• Glasgow�Coma�Scale�(GCS)
www.cdc.gov/traumaticbraininjury/severe.html
Severity GCS
Mild 13Ͳ15
Moderate 9Ͳ12
Severe 3Ͳ8
Traumatic�Brain�Injury
• Not�all�blows�or�jolts�to�the�head�result�in�a�TBI.�
• The�severity�of�TBI�may�be�classified�as�mild,�moderate,�severe�or�penetrating
• The�severity�of�a�TBI�is�determined�at�the�time�of�injury
• Severity�does�not�describe�functional�impairments,�duration�of�symptoms,�or�outcome�following�rehabilitation
Centers�for�Disease�Control�and�Prevention�(2015).
Leading�Causes�of�TBI
Falls35%
MVA17%
Struck17%
Assualts10%
Unknown21%
Centers�for�Disease�Control�and�Prevention�(2014)
4
Sports�Concussion
• Approximately�300,000�sports�related�traumatic�brain�injuries�occur�each�year
• 8.9%�of�high�school�athlete�injuries
• 5.8%�of�all�collegiate�athlete�injuries
• Highest�rates�of�concussion�in�football�for�males�and�soccer�for�females
Gessel,�Fields,�et�al.
Military�Concussion/TBI
• SelfͲreports�indicate�15Ͳ20%�of�those�have�sustained�mTBI
• True�numbers�remain�unknown
CornisͲPop�et�al.�(2012)
5
Are�Blast�Related�TBI’s�Different?
• No�cognitive�differences
• Increased�incidence�of�comorbidities
• Research�is�working�to�determine�cellular�changes
Screening�Tools• Acute�Concussion�Evaluation
• Concussion�in�Sports�Palm�Card
• Military�Acute�Concussion�Examination
Signs�and�Symptoms
• Physical
• Cognitive
• Emotional
Functional�Signs�and�Symptoms
• Physical�or�cognitive�fatigue• Follow�a�conversation• Confusion�or�irritability�• Socialization�changes• Difficulty�modifying�behavior• Difficulty�learning�and�recalling�new�information• Change�in�work�performance�• Difficulty�beginning�or�completing�tasks
6
Return�to�Activity
• Emphasizes�gradual�return�to�physical�and�cognitive�activities�
• Return�timeline�may�vary�for�each�individual
• Too�much�activity�too�soon�can�worsen�symptoms�or�delay�recovery
Return�to�Activity
Return�To�Activity Important�NSI�Symptoms
• Symptoms�Important�to�the�SLP– Hearing�difficulty– Sensitivity�to�Noise– Difficulty�concentrating,�easily�distracted– Difficulty�with�recall– Difficulty�making�decisions– Slowed�thinking– Difficulty�getting�organized– Difficulty�finishing�tasks– Difficulty�falling�asleep– Poor�frustration�tolerance– Easily�overwhelmed�
7
Normal�Course�of�Recovery
• Most�individuals�resolve�symptoms�within�two�weeks
• Follow�Return�to�Activity�and�Physician�recommendations
• PostͲtraumatic�amnesia�and�an�increased�number�of�symptoms�as�the�time�of�the�event,�may�indicate�increased�recovery�time
Assessment
• Receive�Patient• Review�of�the�patient’s�history�within�the�medical�chart
• Patient/family�interview• Address�Symptoms• Combination�of�standardized�and�nonͲstandardized�assessment�procedures
• Provide�Education
Assessment
• Patient�Interview– Brain�Injury�or�Concussion�history– Timeline�of�symptoms�occurring�with�more�than�one�brain�injury
– Health�History– Education– Present�Symptoms– Functional�Deficits
Assessment
• Motivational�Interviewing– Helps�build�rapport�with�patient
– Identify�Ambivalence�
– Patient�identifies�he/she�is�an�“expert”�in�his/her�own�care
8
Assessment
• Standardized�and�NonͲStandardized�Assessment�Tools– Acute�or�Chronic
– Clinical�setting
–What�assessment�procedures�will�best�capture�the�patient?
Assessment
• Standardized�Assessments– Functional�Assessment�of�Verbal�Reasoning�and�Executive�Strategies�(FAVRES)
–Woodcock�Johnson�IV
Assessment
• Assessment�of�cognitiveͲcommunication�challenges�in�Service�Members�and�Veterans– Presence�of�comorbidities– Issues�to�realͲlife�situations– Family�Roles– Social�and�Community�Participation– Return�to�duty,�work,�school
Treatment
• Designed�around�results�of�evaluation�and�patient�interview
• Focus�on�function
• Emphasis�on�strategies
9
Treatment
• Motivate�the�patient
• Clinician�Developed�Goals
• Patient�Developed�Goals
• Educate�Family
Treatment
• Mindful�of�personal�factors
• PreͲinjury�education�level
• Vision/Hearing�Needs
• Remember�every�patient�learns�differently
Treatment
• Emphasize�expectancy�of�recovery
• Provide�education�regarding�positive�outcomes�
• Highlight�the�patient’s�skills
• Positive�expectation�of�recovery�found�to�be�effective�in�reducing�long�term�complaints
(CornisͲPop,�et�al.)
Treatment
• Symptomatic�Intervention
• Train�compensatory�and�metacognitive�strategies�
• Treatment�should�be�embedded�into�meaningful�contexts�individualized�to�patient
• Instill�Confidence�in�his/her�skills�
10
Treatment• Recovery�from�combatͲrelated�concussion/mTBIcan�be�complicated– Physically�and�emotionally�traumatic�circumstances
– Potentially�repetitive�cumulative�nature�of�concussions�sustained�over�a�tour
– Comorbidities
– Difficulty�following�postͲconcussion�care�in�deployment�setting
Goal�Attainment�Scaling
• GAS�process�captures�functional�and�meaningful�aspects�of�a�client’s�progress
• The�goals�are�weighted�by�the�patient
• Difficulty�is�determined�by�the�SLP
Lewis,�Dell,�Matthews.
Goal�Attainment�Scaling• Scaling�the�Goal
– Level�0���This�is�the�level�the�team�believes�can�be�achieved�by�the�specified�time
– Level+1�Patient�performs�somewhat�better�than�expected
– Level+2�Patient�performs�much�better�than�expected
– LevelͲ1�Patient�performs�somewhat�less�than�expected
– LevelͲ2�Patient�performs�much�less�better�than�expected
+2 I�will�utilize my�planner�each�day�to�improve�my�recall�of�daily�tasks�without�external�cues.
+1 I�will�utilize�my�planner each�day,�to�improve�my�recall�of�daily�tasks,�with�one�external�cue.
0 I�will�utilize�my�planner each�day,�to�improve�my�recall�of�daily�tasks,�with�three�external�cues.
Ͳ1 I�currently�utilize�my�daily�planner, to�improve�my�function,�only�when�provided�cues�from�others.
Ͳ2 I�will�not�utilize�my�daily�planner.
Lewis,�Dell,�Matthews.
Treatment• Focus�on�Function– What�does�the�patient�want�to�improve?
– What�does�he/she�need�to�be�able�to�do�in�order�to�return�to�work�or�school?
– Increased�motivation�when�the�patient�sets�his/her�own�goals�
– Must�practice�strategies�with�functional�tasks�in�and�across�sessions
11
Strategies
• Cognitive�Strategies–Memory�Strategies
– Attention�Strategies
– Executive�Function�Strategies
– Environmental�Modifications
Memory�Strategies
• Memory�Strategies– External�(supports�within�the�environment)• Notebook/Planner• Alarms• Apps• Smartpens• Color�Coding• Item�Location�tray• Wireless�leash�for�items
Memory�Strategies
• Internal�Memory�Strategies– Association– Visualization– Grouping– Linking– Acronyms/Mnemonics– Chunking– Repetition/Review–Memory�Palace
Memory
• Memory– Common�complaints:�forgetting�appointments,�instructions,�names�of�individuals,�losing�items
– High�incidence�with�decreased�attention
– Important�to�use�external�memory�aids�with�internal�strategy�training
12
Memory
• Memory�Tasks– Recall�information�from�item�read– Recall�instructions– Recall�conversations– ToͲdo’s–Weapon�System– Education– Child’s�school�schedule– Routes/directions
Attention�Strategies
• Attention�Strategies– Awareness�of�attention�limits– SelfͲtalk– Repeat�information– Decrease�environmental�distractions– Increase/decrease�noise– Tell�self/visual�reminders�to�pay�attention– Breaks
Attention�
• Attention�and�Processing�Speed– Focus�on�practicing�strategies�for�individualized�complaints• Following�multipleͲstep�directions�in�the�presence�of�distractions�
• Reading�with�identification�of�target�words• Sustain�listening�to�auditory�information�over�time�with�or�without�distractions
• Alphabetizing/sorting�information�with�auditory�stimuli• Being�Mindful�of�actions
Executive�Functions
• Strategies– Slow�Down
– External�Supports
– Self�and�Situational�Awareness
– Start�all�tasks�with�the�End�Goal�in�Mind
13
Executive�Functions
• During�a�task�have�patient�follow1. Done�(What�will�it�look�like?)2. Do�(What�do�I�need�to�do/gather/know�for�it�to�
match�the�done�picture?)3. Get�Ready�(Do�I�have�everything�I�need?)4. Start5. Check�(Time�Markers)6. Stop�(Review)7. Correct/Repair�(If�needed)
Executive�Functions
• Executive�Functions– Consider�STOP�For�Situational�Awareness��(Space,�Time,�Objects,�People)
– Space:�What�is�going�on?– Time:�Time�to�complete�task,�what�is�coming�up,�pace�I�need�to�work
– Objects:��How�are�things�organized?��Purpose�and�location
– People:�Read�other�people�(speech,�body�language,�pace�of�working)
Executive�Function
• Executive�Function�Strategies– Using�a�planner�or�calendar�
– Explore�If,�Then�Thinking
– Focus�on�Starting�with�the�End�Goal�in�Mind�(What�will�it�look�like?)
Executive�Functions• Time�Management– Daily�Planner�Provides�Visual
– Prioritize�Tasks
– Visualize�the�End�Point
– Factor�in�time�for�unexpected�
– SetͲup�Time�Checks
14
Treatment
• Helpful�Treatment�Resources
– Attention�Process�Training
– Problem�Solving�Therapy�Program
• Utilize�functional�treatment�tasks
Language
• Common�Complaints:�word�finding,�syntax�in�speech�and�written�language
• Processing�speed,�attention�and�executive�functions�play�a�role
• Focus�on�SelfͲAwareness
Pragmatic�Language
• Education
• Identify�positive�communication�strategies
• Importance�of�Listening
• Address�social�avoidance
Pragmatic�Language
• Reaction�Response– Identify�Symptoms�and�Management
– Identify�Consequences
– Others’�views�on�actions
–Modifying�Behaviors
15
Pragmatic�LanguageSymptoms Reaction/Response Management�of�
SymptomsPositive�Outcomes�
of�Reaction/Response
Negative�Outcomes�of�
Reaction/Response
What�I�will�do�different�next�time
Cognitive:
Behavioral:
Emotional:
Physical:
Fluency
• Fluency�Disorders– Not�typical�symptom�of�concussion�or�mTBI
– Increased�incidence�of�fluency�referrals�for�service�members�and�veterans
– Focus�on�strategies,�in�training�of�easy�to�difficult�situations
Group�Treatment
• iROC (Interdisciplinary�Rehabilitation�Outpatient�Course)
• Focuses�on�a�holistic�approach�to�restore�highest�level�of�function
• Encourages�patient’s�to�manage�their�own�symptoms�to�improve�their�quality�of�life
Group�Treatment
• iROC– SLP– Occupational�Therapy– Behavioral�Health– Creative�Media– Physical�Activity– Education
16
“My�mask�represents�my�struggles�with�decisions�and�situations,�where�memories�feel�like�replayed�scenes�and�decisions�to�leave�every�and�all�things,�to�be�back�in�the�lonesome,�yet�peaceful�wilderness.��The�scars�to�are�somewhat�physically�and�emotionally�visible.”��
Education
• As�a�speech�language�pathologist�you�have�an�obligation�to�educate�others�
• Increase�Knowledge
• Prevention
• Management
ReferencesBrown,�Mannix,�et�al. Effect�of�Cognitive�Activity�Level�on�Duration�of�PostͲConcussion�Symptoms. Journal�of�the�American�Academy�of�Pediatrics, 2014.�Web.��20�Mar.�2015.�
Centers�for�Disease�Control�and�Prevention.�"HEADS�UP�to�Health�Care�Providers:�Tools�for�Providers." Centers�for�Disease�Control�and�Prevention (2015).�Web.�27�Mar.�2015.
ͲͲͲ.�Get�the�Stats�on�Traumatic�Brain�Injury�in�the�United�States.�2010.�Web.�27�Mar.�2015�
Cicerone,�Dahlberg,�Kalmar,�et�al. “EvidenceͲBased�Cognitive�Rehabilitation:�Recommendations�for�Clinical�Practice.” Archives�of�Physical�Medicine�and�Rehabilitation�81.12�(2000):�1596Ͳ1615.�Print.�
CornisͲPop,�Mashima,�et�al.�“CognitiveͲcommunication�Rehabilitation�for�CombatͲrelated�Mild�Traumatic�Brain�Injury”�The�Journal�of�Rehabilitation�Research�and�Development�JRRD 49.7�(2012);�xiͲxxv.�Web.�
Defense�and�Veterans�Brain�Injury�Center. DoDWorldwide�Numbers�for�TBI�Worldwide�Totals.�2014. Web.�March�2015.�
Gessel,�Fields,�et�al.�“Concussions�Among�United�States�High�School�and�Collegiate�Athletes.”�Journal�of�Athletic�Training�42.4�(2007):�459Ͳ503.�Print.�
Lewis,�Dell,�Matthews.�“Evaluating�the�Feasibility�of�Goal�Attainment�Scaling�as�a�Rehabilitations�Outcome�Measure�for�Veterans” Journal�of�Rehabilitation�Medicine�45.4�(2013):�403Ͳ409).�Print.
McCulloch,�Goldman,�Lowe,�et�al.�Development�of�Clinical�Recommendations�for�Progressive�Return�to�Activity�After�Mild�Traumatic Brain�Injury:�Guidance�for�Rehabilitation�Providers.�Journal�of�Head�Trauma�Rehabilitation, 30.1 (2015):�56Ͳ67.�Print.
Ryu,�Jiwon,�Iren�HorkayneͲSzakaly,�et�al.�"The�Problem�of�Axonal�Injury�in�the�Brains�of�Veterans�with�Histories�of�Blast�Exposure." Acta NeuropathologicaCommunications.�BioMed Central,�n.d. Web.�26�Mar.�2015.
Tsaousides,�Theodore,�and�Gordon,�Wayne.�“Cognitive�Rehabilitation�Following�Traumatic�Brain�Injury:�Assessment�to�Treatment.”�Mount�Sinai�Journal�of�Medicine 76�(2009):�173Ͳ181.�Print.�