Transcript Occupational Therapy*s Role in Post Concussion Management

Occupational Therapy’s
Role in Post Concussion
Management
Aimil Parmelee, MOT, OTR/L
Marlaina Montgomery, MOT, OTR/L
Incidence

1,300,000 individuals suffer a mild TBI each year in the U.S.

Total yearly cost is around $60 billion

75% of all TBI are concussions

At risk groups:

Children 0 to 4 years
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Older adolescents aged 15 to 19 years
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Older adults aged 65+ years
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Adults aged 75 years and older have the highest rates of TBI-related hospitalization
Definition of “Concussion”

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“a complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces”
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Direct or indirect blow, impulsive force to head
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Rapid onset & short duration of s/s, spontaneous resolution of s/s
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Functional disturbances rather than structural
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LOC is not a prerequisite
Neuroimaging

Routine neuroimaging (head CT, MRI) is recommended if there is
concern for a structural injury, a focal neurological deficit, or
worsening neurologic status.


Often times not indicated
CT is always normal in concussion:

inclusion criteria for mild TBI

exclusion for moderate to severe TBI
Symptoms of Mild TBI

Appears dazed or stunned
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Confusion (unsure of game, score, or
opponent)
Headache ( most common
symptom; 93%)
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Balance problems or dizziness
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Double vision
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Pain with looking at bright light
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Ringing in the ears
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Feeling sluggish or slowed down
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Feeling foggy or groggy
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Does not “feel right”
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Uncoordinated movements (stumbling)
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Unable to recall words that were just
spoken to them
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Loss of consciousness, even if brief (
Only 10% of all concussions have a loss
of consciousness)

Behavior or personality changes

Amnesia

Nausea
Acute Concussion Symptoms vs. Post
Concussion Syndrome
Acute Concussion

Successful concussion recovery
requires both physical and mental
rest in the beginning. This is
followed by a gradual return to
normal activities while managing
symptoms. This can be a challenge
for adults with many demands at
home and at work.
Post Concussion Syndrome

Typically concussion symptoms
improve in 7-10 days. When those
symptoms last longer than that, it
is called Post concussion syndrome
(PCS). The symptoms of PCS vary
from person to person and fall into
4 categories: physical difficulties,
thinking and memory issues,
emotional issues, and sleep issues.
Often, people with PCS have not
had enough physical or mental rest
after injury to allow for healing.
Post Concussive Personality
•
A
Anxious
 Fearful
 Labile
 “Intense”
 Difficulty sleeping
 Difficulty
concentrating
 “Agitated”

Differential Diagnosis and Comorbid
Complications
 Concussion
vs. Mild to Moderate TBI
 Lyme’s
Disease
 Normal
Pressure Hydrocephalus
 Mental
Health
 Other
Occupational Therapy Evaluation

Past Medical History

Current Medical History
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Past neurological history (migraine, seizure, CVA, prior
concussions)
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Current Medications

Support Structure & home environment

Work & family roles
Evaluation: Sport Concussion Assessment
Tool
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Objective measure to rank
symptoms
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Uses Likert scale to rate
severity of symptoms
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Symptom Scores ranging
from 0 to 22

Severity Score from 0 to
132
Evaluation: IADLS
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Financial Management
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Complex Home
Management Tasks
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Child Care

Work
Evaluation: Cognition
Screening Tools
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Montreal Cognitive Assessment
(MoCA)
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St. Louis University Mental Status
(SLUMS)
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Trails A & B
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Clock Drawing
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Allen Cognitive Level Screen
Evaluation: Cognition
Focus on Functional Complaints
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Look for clusters
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Consider working memory,
processing speed, pace, need
for recheck, double check, loss
of confidence
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Anxiety management
Evaluation: Vision Subjective
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Visual History
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Prescription lens use
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History of Eye Surgery , other
conditions
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Screen Time
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Reading Tolerance
Evaluation: Vision Objective
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Acuity
Oculomotor
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Tracking/Smooth Pursuits
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Saccades
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Convergence/Divergence
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Normal 2-3inches
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Near/Far
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Visual Scanning Sheets
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Brain Injury Visual Assessment
Battery
Evaluation: Vision Objective
Vestibular Screen
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Vestibular Ocular Reflex (VOR)
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Dynamic Visual Acuity
Analyzing the Environment
Auditory and Visual
Environment
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Intensity
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Amount
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Competing Stimuli
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Predictability
Intervention: Environmental
Modifications
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Strategies to eliminate provocative stimulus for symptom management
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Sunglasses
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Earplugs
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Scheduled rest breaks 5-10 minutes removing self from environment
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Alter Lighting
Encourage graded exposure based on symptoms resolution
Intervention: Adaptive Approach to
Oculomotor Skills
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Line blocking or Typoscope
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Increasing visual contrast
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Yellow acetate paper overlay to
darken words
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Glare Glasses or Tinted Lenses
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Screen Filter
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Use of “f.lux” or decreasing
computer backlighting
Intervention: Remedial Approach to
Oculomotor Skills
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Fixation
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Maintaining focus on target without distraction
Pursuits
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Following targets: Ball around Frisbee, swinging ball,
laser pointer
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Mazes
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Scanning sheets
Saccades
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Switching targets at various distances
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Switching lines, reading columns, connecting dots
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Wide search/Environmental Search
Convergence
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Pencil Pushups: Bringing object toward face until double
image, just prior to double image holding gaze and
returning to start position
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Brock String: Three beads placed at various distances on
string to promote visual focus on object at various
distances
Intervention: Adaptive Approach to
Cognition
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Start with low tech
options with good visual
support
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Education around fatigue
and anxiety
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Education on memory loop

Decrease Cognitive Load
and environmental press
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Paradigm Shift
Intervention: Remedial Approach to
Cognition


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Gradually increase Environmental
press and task complexity
Attention Training – monitor and
accommodate for visual deficits
Working on increase speed,
efficiency, and timeliness of tasks
Task and Environment
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Phase 1
Phase 2
Environment
Phase 2
Task
Phase 4
Intervention: Return to Work

Coverage for OT Services
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Job Specific
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Outline Job Tasks
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Initial adaptation plan
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Gradual increase over months
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Highly motivated to return offers
opportunities for set backs
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Consider underlying cause for
resisting return to work
Interdisciplinary Roles
Physical Therapy
Speech Therapy
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Return to Play
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Return to Learn
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Balke: Autonomic regulation
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Cognitive Linguistic Deficits:

Vestibular Ocular Reflex (VOR)
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Attention

Vestibular Dysfunction (Vertigo)

Processing Speed
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Dynamic Visual Acuity – Gaze
stabilization
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Memory/recall
Recommended Referrals
Neurology
 Prolonged, persistent headaches
 Poor progress with inter-disciplinary rehab team
 Psychology and Psychiatry
 Patients presents with symptoms of depression, anxiety, and
irritability
 Neuro Optometrist or Ophthalmologist
 Visual symptoms that last greater that 6 month post injury
 Patients with history of eye surgery or pre-existing eye
conditions
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Questions
Reference

Clock Drawing Test. https://www.healthcare.uiowa.edu/igec/tools/cognitive/clockDrawing.pdf

Centers for Disease Control Website http//www.cdc.gov/concussion/

Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to
Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem.
Atlanta (GA): Centers for Disease Control and Prevention; 2003.

Fisher, A. G., Bray Jones, K. (2011) Assessment of Motor and Process Skills. Volume I:
Development, Standardization, and Administration Manual. Seventh Edition Revised. Fort
Collins, CO. Three Star Press.

Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department
visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control; 2010.

Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United
States. New York (NY): Oxford University Press; 2006.

Finn, C, Waskiewicz, M. The Role of Occupational Therapy in managing post-concussion syndrome. 2015; 38

Mangen, A. Walgermo, B, Bronnick K. Reading linear texts on paper versus computer screens. Effects on
reading comprehension. Int J Educational Res. 2013; 58: 61-68
References

MoCA Montreal – Cognitive Asssessment. http://www.mocatest.org/

Shulman, K. I., Gold, D. P., Cohen, C. A., Zucchero, C. A.,(1993). Clock Drawing for dementia in the
community: a longitudinal study. Internaltional Journal of Psychiatry.

Sports Concussion Assessment Tool – Third Edition. http://bjsm.bmj.com/content/47/5/259.full.pdf

Suter, P, and Harvey, L. Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury; 2011.

Tariq,m S. H., Tumosa, N., Chibnall, J.T., Perry, H.M., Morley, J.E. (date). The Saint Louis University
Mental Status (SLUMS) Examination for Detecting Mild Cogntive Impairment and Dementia is more
sensitive than the Mini-Mental Status Examination (MMSE) – A pilot study. Journal of American
Geriatric Psychiatry. http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

Trails A and B. http://doa.alaska.gov/dmv/akol/pdfs/uiowa_trailmaking.pdf

Unsworth, C. (1999). Cognitive and Perceptual Dysfunction: A Clinical Reasoning Approach to
Evaluation and Intervention. Philadelphia, PA. F. A. Davis Company.

Zoltan, B.(2007) Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of
the Adult With Acquired Brain Injury Fourth Edition. Thorofare, NJ. Slack Incorporated.