Benefits of a Multidisciplinary Approach to Managing Concussions (mild TBIs)

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Benefits of a Multidisciplinary Approach to
Managing Concussions (mild TBIs)

• Jenna Katorski, RN, CNP, MS
• Nicole LaBerge, PT, ATP
• Candice Gangl, OTD, OTR/L

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Objectives

• Define minor Traumatic Brain Injury (mTBI)
• State how to access academic accommodations for
  patients after a mTBI
• State the role and benefit of vestibular therapy
  and the Return to Activity Protocol in Physical
  Therapy treatment of patients with a mTBI
• Identify differences between the role and
  treatment goals of Speech and Occupational
  Therapy for patients with a mTBI

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Meet Pat

• 17 year old
• Senior high school soccer player
• A/B student
• No history of injuries
• No significant past medical history

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Oh No! Pat Got Smacked!

• Pat got elbowed in the right side of the head
  during a soccer game.

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Pats Initial Symptoms

• No LOC (Loss of Consciousness)
• HA (Headache)
• Dizziness
• Vision deficits

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Pats Removed From Play

• Because of the MN Law, coach/trainer aware to
  remove from play immediately.
• Under age of 18 years, playing in a sport, if
  concussion is suspected, must remove from play
  until medically cleared
• Coaches must take CDC training
• Parents must sign form

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Pat sustained a mTBI
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What is a mild traumatic brain injury (mTBI)?

• There are a few names for a mild traumatic brain
  injury.
• Concussion
• Getting your bell rung
• Getting a ding
• When there is an injury to the head, spine, or
  body that causes brain to move rapidly inside the
  skull, this affects the cells inside the brain.
  The cells can not make as much energy.

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Causes of TBI
Sports-Related Head Injuries 300,000 per year
in U. S. Recreation TBI Deaths gt 500 per year
MVA
Other
Assaults
Sports
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What happens to brain energy after an injury?

• The brain needs energy to heal the injury.
• After an injury the brain cells cannot make as
  much energy. It is important for the brain to
  rest so that it can make energy to heal the
  injury.
• During the recovery, activities that use brain
  energy may become more difficult, or may make
  symptoms worse.

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Post Concussion Syndrome

• Post-concussion syndrome is a complex disorder in
  which a combination of post-concussion symptoms
  such as headaches and dizziness last for weeks
  and sometimes months after the injury that caused
  the concussion.

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Second Impact Syndrome

• When a second TBI occurs before the brain heals
  from the first
• Second injury may cause diffuse cerebral edema
  (brain swelling) and other widespread damage.
  This can be fatal.
• The second impact can occur days, weeks or months
  after the initial TBI.

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Pat Goes to a Primary Care Provider

• Evaluated by PCP the next day and placed on
  physical and cognitive rest.
• Follow up one week headache, dizziness, visual
  problems.
• Follow up two week continues to have headache,
  dizziness, visual problems. Noticing decline in
  school performance difficultly sleeping.

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Sign Symptoms of mTBI
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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 Nervousness Trouble falling asleep
Visual problems -49 Forgetful of recent events
Sensitive to light -47 Confusion about recent events
Vomiting Answers questions more slowly
Nausea Repeats questions
Sensitive to noise
Numbness/tingling
Dazed/Stunned
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Assessment and Diagnosis of mTBI
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Assessment

• Physical exam to rule out bleed, neck injury,
  spine injury
• Assess physical symptoms
• Neurocognitive screening/developmental screening
• CT scans and MRIs of the head are usually normal
  and are not necessary unless the patient has
  increasing symptoms of concern

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Diagnosing mTBI

• Report of symptoms consistent with mTBI
• Cognitive testing-ImPACT (Immediate
  Post-concussion Assessment Cognitive Testing)
• Evaluation by speech therapy, occupational
  therapy, physical therapy, psychology,
  neuropsychology.

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Pats Exam

• Physical Exam
• Poor visual tracking
• Assessment of ocular movements provokes symptoms
  of increased headache and dizziness
• Poor balance
• Cognitive Screen
• Computer based neurocognitive ImPACT scores below
  expected level

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• Management

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Goals of post injury management

• Prevent against Second Impact Syndrome
• Prevent against cumulative effects of injury
• Prevent presence of Post-Concussion Syndrome
• Determination of asymptomatic status essential
  for reducing repetitive and chronic morbidity of
  injury
• Post injury cellular metabolism is over worked,
  thus the cells are more vulnerable to further
  insults and injuries.

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Management

• Physical Rest
• Cognitive Rest
• Child needs to limit exertion with activities of
  daily living and limit scholastic activity while
  symptomatic
• Repeated injury or overstimulation during the
  energy crisis of acute brain injury could lead to
  cell death
• Pharmacology
• Management of specific symptoms
• Giza, Hovda. The Neurometabolic Cascade of
  Concussion. J Athl Train. Vol 36, p 228-235,
  2001.

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Rest

• Cognitive Rest
• Typically one week only
• No texting
• No video games
• No recreational reading
• No computer except for school work
• TV, Movies Music are the only activity that is
  allowed

• Physical Rest
• No physical activity
• No sports
• No exercise/working out
• No strenuous activity
• No recess
• No gym class

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What can I do on cognitive rest?

• OK to watch TV, watch movies, and listen to
  music. The volume should be low.
• You can go to school and do homework however if
  school and school work increase your symptoms you
  may need accommodations at school, shortened
  school days or to stay home.

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What can I do on physical rest?

• You can walk with your feet on the ground at a
  casual pace.
• You can go to school (no phy ed, gym class or
  recess).

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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.

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Expected Recovery for mTBI

• Majority of patient require multiple follow up
  appointments for repeat testing and therapies.
• ImPACT test is taken at follow up appointments
  and scores are tracked throughout recovery.
• First we start with physical and cognitive rest
  (it helps if you start this before your first
  visit).
• Next, cognitive activities are added back.
• If cognitive activities are tolerated and testing
  scores are good, then begin Return to Activity
  with physical therapy stages 1-4.
• Begin at stage one and every 3-5 days progress to
  the next.
• After successful completion of stage 4 with
  physical therapy, final testing is done.
• If testing remains at the expected level and all
  symptoms have resolved, then clear for stage 5
  (full contact)

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Why is my recovery taking longer?

• Research has shown that the following factors
  increase change of a longer recovery.
• Age younger patients have longer recovery
• History of 4 or more concussions
• History of migraine headaches
• Exertion (physical activity) after injury
• Length of retrograde amnesia (cannot remember
  events after injury)
• Report of fogginess

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What is done if symptoms do not go away?

• There are a variety of options for post
  concussion symptom management.
• Over the counter medications/vitamins
• Prescription medications
• Therapy
• Referrals to other disciplines
• At Gillette you may have another team member join
  your care team.

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Who else could I meet throughout my recovery?

• 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

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Meet Pats mTBI Team
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Social Work
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Social Work

• What does Social Work do after a Brain Injury?
• Provide information for student resources for
  school and college accommodations
• Assist with locating Disability Services Office
  Coordinator, or schools contact person
• Assist with patient and family needs
• Mental Health Screens
• Chemical Health Screens
• Crisis Resources
• Financial Assistance
• Support Groups
• Community Resources

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Elementary, Middle and High School Accommodations

• Communication with key staff is essential to the
  process.
• 504 Plan to achieve specific accommodations for
  short term duration
• Schools are required to comply

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Psychology Neuropsychology
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Psychology
What does Psychology do after a Brain Injury?

• Psychology
• 1 hour interview about 2 hours testing
  feedback session and letters for accommodations

• Neuropsychology (more complex cases)
• 1 hour interview about 3 hours testing
  feedback session and letters for accommodations
• Focused follow-up assessment

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Psychotherapy Treatment

• Premorbid psychological issues (depression,
  anxiety, ADHD, etc)
• Coping and adjustment issues
• Control behavior
• Manage emotions

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Pat

• Social Work
• Assist with school accommodations/contact person
  at HS
• Provide family resource, steps to take to
  establish 504 Plan
• Understand stress of situation with both Pat and
  family
• Psychology/Neuropsychology
• Behavior Therapy
• Formal testing completed to establish
  accommodations needed for ACT and College Classes

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Physical Therapy
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Physical Therapy

• What 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

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TRAUMATIC BRAIN INJURY Evaluated by a Medical
Professional
ImPACT Testing
Scores WNL No Symptoms
Scores not WNL Symptoms present
Physical Therapy Evaluation
Return to Activity
Vestibular and Balance
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Physical Therapy

• Vestibular/Oculomotor Function
• Assess how the Brain, Inner Ear, and Eyes are
  working together
• Looking for any abnormal results during the
  assessment
• Asking patient if any of the tests are producing
  symptoms during/after
• Can provide Canalith Re-Positioning (if
  appropriate) and also home exercise that day, to
  help with symptoms

• Balance Tests
• BESS (Balance Error Scoring System)
• DGI (Dynamic Gait Index)
• FGA (Functional Gait Analysis)

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Physical Therapy

• Return to Activity Protocol
• Provide education to patients/families on how to
  find target heart rate
• 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

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Pat

• Vestibular and Balance Testing because of
• Dizziness
• Headaches
• Difficulty focusing
• Motion sickness
• Nausea
• Blurry Vision
• Sensitivity to Light/Sound
• Loss of balance when turning head and looking up

• Treatment
• Epley Canalith Repositioning Manuever (symptoms
  of BPPV)
• Home program for vestibular/oculomotor exercises
• Home program for Balance activities

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Pat

• Symptoms Decreased Provider approved start of
  Return to Activity Protocol
• Stages I-IV completed during separate PT
  treatment sessions (1 week apart)
• Heart Rate monitoring
• Treadmill
• BOSU
• Dynamic activities with head/eye movements
• Strengthening/Flexibility
• Soccer Drills

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Occupational Therapy
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Occupational Therapy

• What does OT do after a brain injury?
• After a traumatic brain injury you will likely
  have changes with your day-to-day life as you
  heal. Sometimes, things return to normal on
  their own, other times some help is needed. OTs
  can help you work with areas that continue to be
  difficult. We will provide ideas to strengthen
  skills and make changes to your environment. Our
  goal is to help you return to school, work, and
  daily activities.

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Occupational Therapy

• Why referred 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

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Occupational Therapy

• What OT did at Pats evaluation
• Pt. and family symptom interview
• Vision Screen
• Behavior Rating Inventory of Executive
  Functioning (BRIEF)
• Toglia Calendar task assessment (Executive
  functioning skills)
• Montreal Cognitive Assessment (MOCA)
• These tests are not all inclusive of testing
  used for these Pts.

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Occupational Therapy

• Treatment Activities
• Vision
• -Treatment with exercises for Convergence and
  Saccades.
• -Compensation Overlays, highlighter guides,
  larger fonts
• Cognition
• -Practice and Strategies breaking down tasks,
  memory strategies
• -Compensation planners, alarm reminders,
  calendars, lists, voicemails, e-mails, picture
  schedules, advocating for self, school
  accommodations
• Sensory Sensitivity
• -Graded introduction of stimuli
• -Compensation Sunglasses, tinted glasses,
  earplugs
• Daily Activities
• -Completing the difficult activities in graded
  environments with use of compensation as needed
• -Cooking example

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Occupational Therapy

• Discharge Goal
• Pt. is able to complete tasks 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!

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Speech Therapy
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Speech-Language Pathology

• What does SLP do after a mTBI?
• Management of cognitive communication disorders
• Difficulty with language/communication as a
  result of impairments in general cognitive
  processes of attention, memory, executive
  functions and processing speed.

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What does the SLP do?

• Evaluate cognitive strengths and weaknesses
  related to language and communication for social
  and academic/vocational use following TBI.
• Treatment involves helping patients and families
  implement language, communication, behavioral
  self-regulation strategies and adaptations to
  address disabilities in communication at home, in
  community, and school/work following mTBI.
• Education of patients, family, and staff on
  importance of communication.

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The Speech Referral

• Why is Pat referred to speech?
• Trouble talking with family and friends
• Word finding problems
• Disorganized thoughts and speech
• Difficulties remembering test information
• Inability to organize written information at
  school

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Assessment

• Assessments are and should be flexible and guided
  by patient factors, history, and chief
  complaints. The assessments used were focused on
  activities and participation with some
  body/function information as needed.
• Subtests of the Woodcock-Johnson III.
• Assess discourse level complex language
  narrative and/or expository monologues, story
  retell (immediate and delayed).
• Questionnaires (e.g. La Trobe Communication
  Questionnaire, Everyday Memory Questionnaire,
  others).
• Identify patient-centered goals What does Pat
  want to do?

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Pats SLP treatment

• Training use of external aids
• Template for paper composition, use of checklists
• Training use of internal cognitive aids
• Pneumonic devices, visual imagery
• Training environmental supports
• May target patient and/or caregivers and family.
• Training of scripts
• Role play job interview

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Pat Is Back!
Hooray!
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Conclusion

• It is our responsibility to be able to recognize
  signs and symptoms of a concussion.
• Begin physical and cognitive rest immediately.
• Absence of physical symptoms does not indicate
  full recovery, as neurocognitive deficits may
  still be present.
• Management and rehab may require multiple
  disciplines.
• Proper evaluation and management of brain
  injuries is necessary to avoid potential
  catastrophic injury/event.

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Conclusion

• There are many pieces to the Patient Puzzle
• Multidisciplinary management is effective to
  fully treat the patients needs
• We have had the most success working together and
  sharing ideas
• Each patient is different with an individualized
  care team

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QUESTIONS?
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Resources

• Centers For Disease Control www.cdc.gov/concussion
  /index/html
• Immediate Post-Concussion Assessment and
  Cognitive Testing (ImPACT) www.impacttest.com
• Brain Injury Association of Minnesota
  www.braininjurymn.org
• Minnesota Department of Education TBI Program
  Email Deb.Williamson_at_metroecsu.org

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Facts for Physicians booklet    Acute
Concussion Evaluation (ACE) form    ACE Care
Plan Work version  School version  
 Concussion in Sports palm card  
CDCHeads Up Brain Injury in your Practice
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Website from the CDC for Concussion Training

• Free Heads Up Concussion in Youth Sports
  training course through the CDC? It is designed
  for parents/coaches or anyone involved in youth
  sports. The goals are
• Understand a concussion and the potential
  consequences of this injury,
• Recognize concussion signs and symptoms and how
  to respond,
• Learn about steps for returning to activity (play
  and school) after a concussion, and
• Focus on prevention and preparedness to help keep
  athletes safe season-to-season.  
• http//www.cdc.gov/concussion/HeadsUp/online_train
  ing.html

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Contact Information

• Jenna Katorski, RN, CNP, MS
• JennaRKatorski_at_gillettechildrens.com
• Nicole LaBerge, PT, ATP
• Nicole.laberge_at_gillettechildrens.com
• Candice Gangl, OTD, OTR/L
• CGangl_at_gillettechildrens.com