Disclaimer. Individualized Management and Treatment Following Traumatic Brain Injury. Learning Objectives. Outline

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1 Disclaimer Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC SLP Warrior Recovery Center, Fort Carson, CO 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 cognitive communication deficits associated with concussion and traumatic brain injury Apply treatment techniques for cognitive communication deficits Recognize his/her role in educating others regarding concussion and traumatic brain injury 1

2 Sometimes I feel lost in a storm, waiting for a break in the clouds Definition A 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) Post traumatic amnesia (PTA) Alteration of Consciousness (AOC) Neurological deficits that may or may not be temporary Intracranial lesion (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) 2

3 Severity Determination Traumatic Brain Injury Glasgow Coma Scale (GCS) Severity Mild Moderate Severe GCS 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 Leading Causes of TBI Unknown 21% Falls 35% Assualts 10% Struck 17% MVA 17% Centers for Disease Control and Prevention (2015). Centers for Disease Control and Prevention (2014) 3

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 Self reports indicate 15 20% of those have sustained mtbi True numbers remain unknown Cornis Pop et al. (2012) 4

5 Are Blast Related TBI s Different? No cognitive differences Increased incidence of comorbidities Screening Tools Acute Concussion Evaluation Concussion in Sports Palm Card Military Acute Concussion Examination Research is working to determine cellular changes 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 5

6 Return to Activity 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 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 6

7 Normal Course of Recovery Most individuals resolve symptoms within two weeks Follow Return to Activity and Physician recommendations Post traumatic 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 non standardized 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 7

8 Assessment Standardized and Non Standardized Assessment Tools Acute or Chronic Clinical setting Assessment Standardized Assessments Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) Woodcock Johnson IV What assessment procedures will best capture the patient? Assessment Assessment of cognitive communication challenges in Service Members and Veterans Presence of comorbidities Issues to real life 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 8

9 Treatment Motivate the patient Clinician Developed Goals Patient Developed Goals Educate Family Treatment Mindful of personal factors Pre injury 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 Treatment Symptomatic Intervention Train compensatory and metacognitive strategies Treatment should be embedded into meaningful contexts individualized to patient Instill Confidence in his/her skills (Cornis Pop, et al.) 9

10 Treatment Recovery from combat related concussion/mtbi can be complicated Physically and emotionally traumatic circumstances Potentially repetitive cumulative nature of concussions sustained over a tour Comorbidities Difficulty following post concussion 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 Treatment 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 Level 1 Patient performs somewhat less than expected Level 2 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. 1 2 I currently utilize my daily planner, to improve my function, only when provided cues from others. I will not utilize my daily planner. 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 Lewis, Dell, Matthews. 10

11 Cognitive Strategies Memory Strategies Attention Strategies 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 11

12 Memory Memory Tasks Recall information from item read Recall instructions Recall conversations To do s Weapon System Education Child s school schedule Routes/directions Attention Strategies Attention Strategies Awareness of attention limits Self talk 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 multiple step 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 Strategies Slow Down Executive Functions External Supports Self and Situational Awareness Start all tasks with the End Goal in Mind 12

13 Executive Functions During a task have patient follow 1. 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. Start 5. 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 Set up Time Checks 13

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 Self Awareness 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 14

15 Pragmatic Language Fluency Symptoms Reaction/Response Management of Cognitive: Symptoms Positive Outcomes of Reaction/Response Negative Outcomes of Reaction/Response What I will do different next time Fluency Disorders Not typical symptom of concussion or mtbi Behavioral: Emotional: Increased incidence of fluency referrals for service members and veterans Physical: 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 iroc SLP Occupational Therapy Behavioral Health Creative Media Physical Activity Education Group Treatment 15

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 References Brown, Mannix, et al. Effect of Cognitive Activity Level on Duration of Post Concussion Symptoms. Journal of the American Academy of Pediatrics, Web. 20 Mar 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 Get the Stats on Traumatic Brain Injury in the United States Web. 27 Mar Cicerone, Dahlberg, Kalmar, et al. Evidence Based Cognitive Rehabilitation: Recommendations for Clinical Practice. Archives of Physical Medicine and Rehabilitation (2000): Print. Cornis Pop, Mashima, et al. Cognitive communication Rehabilitation for Combat related Mild Traumatic Brain Injury The Journal of Rehabilitation Research and Development JRRD 49.7 (2012); xi xxv. Web. Defense and Veterans Brain Injury Center. DoD Worldwide Numbers for TBI Worldwide Totals Web. March Gessel, Fields, et al. Concussions Among United States High School and Collegiate Athletes. Journal of Athletic Training 42.4 (2007): 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): ). 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): Print. Ryu, Jiwon, Iren Horkayne Szakaly, et al. "The Problem of Axonal Injury in the Brains of Veterans with Histories of Blast Exposure." Acta Neuropathologica Communications. BioMed Central, n.d. Web. 26 Mar Tsaousides, Theodore, and Gordon, Wayne. Cognitive Rehabilitation Following Traumatic Brain Injury: Assessment to Treatment. Mount Sinai Journal of Medicine 76 (2009): Print. 16