What Comes Next Aftera Concussion?STEPHANIE HAYS, PT, DPTADAM EWALD, MOT OTR/L CSRSGRACE KNOX, MS, CCC-SLP
What is a Concussion?uAccording the AANS:uA concussion is an injury to the brain that results in temporary loss of normal brainfunction. It usually is caused by a blow to the head. In many cases, there are noexternal signs of head trauma. Many people assume that concussions involve a lossof consciousness, but that is not true. In many cases, a person with a concussionnever loses consciousness.
Types of Concussions/Mechanisms ofInjuryuA direct impact to the head is by far the most common mechanism ofencountering a concussion.uIt can be caused by a stable object like the floor or from an object in motion,like a baseball or hockey stick.uSporting activities, such as football and hockey, or car that involve greaterlevels of contact and collision will present with increased risk of concussioninjuries.
Common Symptoms After ConcussionuuuuuuuuuuuuuuuHeadacheDizzinessMental fogginessAmnesiaEmotional abilityFatigueSlowed reaction timeSensitivity to light/noiseSleep disturbancesVision deficitsNeck pain
Signs/Symptoms following a ConcussionuHeadache/ MigraineuCervicaluOculomotoruVestibularuCognition/ FatigueuAnxiety
Predictors of Longer RecoveryuNumber and severity of symptoms in the first day (or first few days)uuuuuuDizzinessHistory of previous concussionHistory of migrainesHistory of depression/mental health diagnosisAgeFemale sex
When to Refer to Therapy Refer to PT: for headaches, dizziness, balance/gait impairments, neck pain,vestibular deficits, vertigo/BPPV Refer to OT: for headaches, visual deficits, concentration issues, coordinationdifficulties, memory issues, multisensory processing difficulties and troublewith ADL/IADL tasks Refer to ST: for memory deficits, academic concerns, problem solving issues,concerns about return to work/learn, word-finding deficits, issues withreading/writing
Standardized PhysicalTherapy AssessmentsuVOMSuDynamic BalanceuuStatic BalanceuuFGA/DGIBESSNeuroComuSOTuVOR/ Gaze StabilizationuDynamic Visual AcuityuCervical Spine AssessmentuImPACTuVertigo/ BPPVuBuffalo Treadmill TestuConcussion Grading Scale
Buffalo Treadmill TestuuUsed to establish a safe aerobic exercise programHR and BP are recorded at symptom exacerbation to determine exerciseprescription threshold
Headache/ MigraineuLight/ noise sensitivityuProgresses as day goes on?uWake up with a HeadacheuPost Traumatic Migraine
CervicaluNeck painuLimited neck ROMuPostural dysfunction
OculomotoruDifficulty readinguBlurry visionuDouble visionuHeadache with visual tasks
VestibularuDizzinessuBalance problemsuBlurry vision
Cognition/ FatigueuTirednessuFogginessuMemory deficits
AnxietyuDizzinessuNervousnessuDifficulty sleepinguEmotional issues
Equipment used for testinguNeuro ComuIMPACTuInteractive metronomeuBITS bioness
The Role of the Physical Therapist (PT)uPT evaluation is indicated if pt reports difficulty withuCervical spine limitationsuVestibular deficitsuHeadachesuBalance/gait impairmentsuVertigo/BPPV/ DizzinessuIncreased nausea
How can a Physical Therapist help me?uRest and recoveryuRestoring strength and enduranceuStopping dizziness and improving balanceuReducing headachesuReturning to normal activity or sport.
Cognitive Disorders and Blast Injuries:Fast FactsuMost common cause of injury in Operation Iraqi Freedom and OperationEnduring FreedomuMild Traumatic Brain Injury (mTBI)uThe effects of a blast are different from other sources of TBI (car accident,etc)u10-20% of service members returned from OIF/OEF met criteria for mTBIduring a detailed screening
Cognitive Disorders andPsychological ChallengesuuPsychological challenges common after mTBIuDepressionuIrritabilityuAnxietyuDecreased initative/self-esteemPsychological challenges affect cognitive function!
Support for Cognitive Therapyafter mTBIuThere is a great need for specific research for servicemembers and therapyfollowing concussion!uCurrent research is based on the civilian population.uMemory retraining is helpful, especially use of compensatory devices/strategies.uOrganization of school/work materials is important as well andrequires support from therapist to personalize strategies.
The Role of the Speech Pathologist (SLP)uSLP evaluation is indicated if pt reports difficulty with:uuuuuuFocus/attention to taskShort-term memory recallWord finding in writing or conversationOrganizing/maintaining scheduleProcessing speedSLP will focus on cognitive-linguistic tasks
Standardized SpeechTherapy Assessments Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) Verbal reasoning, complex comprehension, discourse, and executive functioningMontreal Cognitive Assessment (MoCA) Perception/Discrimination, Orientation, Organization, Recall, and ReasoningAttention and concentration, executive functions, memory, language, visuoconstructional skills,conceptual thinking, calculations, and orientationIndividual Tasks Card sort Number/letter trail Attention to task, processing speedExecutive function, working memoryPatients may bring their own tasks (homework, study prep, planner, etc.)
Standardized Speech Therapy Assessments
How can a speech therapist help me?uSLPs can help patients by providing therapeutic strategies:uuuuuuUse of memory recall strategies (association, repetition, writing things down)Spaced retrieval training (increasing time increments of recall)Use of organization strategies (planner, phone calendar)Simulation of cognitive tasks (sort cards with music playing)Use of reading comprehension strategies (highlighting important information inreading passages, pre-reading skills)Test-taking strategies (for tests in school or for college admission tests likeACT/SAT)
The Role of the OT (OT)uOT evaluation is indicated if pt reports difficulty with:uInterference with ADl/IADL'suDifficulty with cognitionuVision difficulties both acuity and visual processinguSensitivity to light/ noiseuSleeping disturbancesuDifficulties with being at school/ workuReducing headaches
StandardizedOccupational Therapy AssessmentsuBrain Injury Visual Assessment Battery (BADS)uDynamic Visual AcuityuMVPT4uCLQTuRivermeaduImPACT
How can Occupational Therapist helpme?uWork on re-organization in the sensory systemuPhysical exerciseuCognitive exerciseuAdaptive Approach for symptomsuRemedial Approach for symptomsuAdvocating for accommodations at school/ work
ReferenceuCenters for Disease Control and Prevention (CDC), National Center for Injury Prevention andControl. Report to Congress on mild traumatic brain injury in the United States: steps toprevent a serious public health problem. Atlanta (GA): Centers for Disease Control andPrevention; 2003uFisher, A. G., Bray Jones, K. (2011) Assessment of Motor and Process Skills. Volume I:Development, Standardization, and Administration Manual. Seventh Edition Revised. FortCollins, CO. Three Star PressuFinn, C, Waskiewicz, M. The Role of Occupational Therapy in managing post-concussionsyndrome. 2015; 38uDeRiesthal, M. (2009). Treatment of Cognitive-Communicative Disorders Following BlastInjury. American Speech-Language-Hearing Association, Perspectives on Neurologyand Neurogenic Speech and Language Disorders.uUnsworth, C. (1999). Cognitive and Perceptual Dysfunction: A Clinical Reasoning Approach toEvaluation and Intervention. Philadelphia, PA. F. A. Davis Company.uZoltan, B.(2007) Vision, Perception, and Cognition: A Manual for the Evaluation andTreatment of the Adult With Acquired Brain Injury Fourth Edition. Thorofare, NJ. SlackIncorporated.
uA concussion is an injury to the brain that results in temporary loss of normal brain function. It usually is caused by a blow to the head. In many cases, there are no external signs of head trauma. Many people assume that concussions involve a loss of consciousness, but that is not true. I