Mild TBI/Concussion Alyssa Min, Jocabehd Lobos, Sarah Cha, Samantha - - PowerPoint PPT Presentation

Mild TBI/Concussion

Alyssa Min, Jocabehd Lobos, Sarah Cha, Samantha Kinoshita, Christine Truong

What is a Mild TBI / Concussion?

• A traumatically induced structural injury and/or physiological disruption of

brain function as a result of an external force that is indicated by new onset of worsening of at least one of the following clinical signs immediately following the event: ○ Any period of loss of or a decreased level of consciousness (LOC) ○ Any loss of memory for events immediately before or after the injury ○ Any alteration in mental state at the time of injury ○ Neurological deficits that may or may not be transient ○ Intracranial lesion

• Referred to as the “signature injury” of the recent conflicts in Iraq and

Afghanistan and accounts for more casualties than in previous wars ○ Combat-related TBI ○ Blast Injuries - Primary, Secondary, Tertiary, Quaternary (Kimbarow, 2016)

Signs and Symptoms

• Signs and symptoms

○ Problems concentrating ○ Headache ○ Dizziness/difficulty with balance ○ Trouble sleeping and then if tired that can compound the problems ○ Sensory impairments ○ Psychological health concerns

• Common deficits

○ Cognitive: memory, learning, reasoning, judgment, attention/concentration ○ Executive functioning: problem-solving, multitasking, organization, planning, decision-making, beginning or completing tasks ○ Intellectual problems ○ Communication problems ○ Behavioral and emotional changes

Prevalence + Incidence

• Prevalence

○ TBI-related disability in rural geographical areas is higher than urban and suburban areas (Centers for Disease Control and Prevention, 2015)

• Incidence

○ According to the DoD. 300.707 of more than 2 million troops, who served worldwide in OIF/OEF, sustained a TBI between 2000 and 2014 with 82.4% classified as mTBI

Etiologies

• Open head injury

○ Results from bullet wounds, etc. ○ Largely focal damage ○ Penetration of the skull ○ Results can be just as serious as closed-brain injury

• Closed head injury

■ Slips/falls ■ Motor vehicle accident ■ Focal damage and diffuse damage to axons ■ Effects tend to be broad (diffuse) ■ No penetration to the skull

Risk Factors & Severity

• Risk factors

○ Military service ○ Sports ○ Falls

• Severity of TBI according to DoD

○ Structural neuroimaging ○ Loss of consciousness ○ Alteration in consciousness ○ Posttraumatic amnesia (often self-reported) ○ Glasgow Coma Scale

Appropriate Assessments

• Scales & Observational Checklists

○ Glasgow Coma Scale (GCS) ■ Score can help determines severity of TBI (2-8) ○ Disability Rating Scale (DRS) ■ Arousability, awareness, self-care activities, independence, etc. ○ Rancho Los Amigos Levels of Cognitive Functioning-Revised ■ Level I (no response) → Level X (purposeful, appropriate, modified-independent) ○ ASHA Functional Communication Measures (FCM) Levels ■ Memory, problem-solving, attention, lang. comprehension, motor speech, etc.

• Standardized Measures include

○ Brief Test of Head Injury (assess cognitive, linguistic & communicative abilities) ○ Scale of Cognitive Ability for Traumatic Brain Injury (SCATBI) ○ Cognitive Linguistic Quick Test (CLQT)

Case Study!

Mild TBI/Concussion

Hypothetical Case - Case Hx

Steve Rogers is a 43 year old, right-handed man. He lives at home with his wife, Peggy and has two adult children, Bucky and Tony. He was a captain in the army before being honorably discharged after serving for 6 years. He was stationed in Wakana during the incident. He was “positioned” in the trenches near a chapel when a grenade blew 30 feet away. He sustained a mild TBI from the blast as well as a closed head injury (CHI) upon impact on the ground. As a result of the blast, his left arm was lost. He reportedly lost consciousness for what seemed like a few minutes. After gaining consciousness, he was not screened for concussion or head trauma on site. He was immediately taken to medical to operate on his arm. Steve returned home after being stabilized and began work with PT and OT. His left arm was amputated and was soon fitted with a vibranium prosthetic arm. In the first three weeks of being home, Steve experienced severe headaches, difficulty focusing, tinnitus, and dizziness. He also experienced PTSD symptoms (i.e. flashbacks) and trouble sleeping. He admitted himself to the VA Hospital because of these concerns. The VA made a referral to speech-language pathology for a full assessment.

Assessment Administration

• Chart notes indicated no significant medical history
• Discuss case with medical team + other professionals

○ General VA physician, audiologist, neurologist, psychologist, OT, and PT

• Non-standardized Measures

○ Pt interview & family interview

• Standardized Measures

○ Montreal Cognitive Assessment (MoCA) ■ Didn’t pass the screener, further testing needed for areas of: visuospatial, attention, memory, and executive function ○ Cognitive Linguistic Quick Test (CLQT) ■ Was presented 10 subtests to assess for cognitive deficits

Assessment Findings

• During patient interview:

○ Steve reported concerns with his memory and his attention span. He feels that it has gotten harder for him to remember things and gets distracted easily as it is hard for him to focus on one thing for a long

• time. He also expressed that he has word finding difficulties, making it

harder for him to communicate with his family

• During family interview:

○ Steve’s wife, Peggy agreed with her husband; she feels his deficits are more severe than Steve thinks they are ○ Steve’s son, Bucky reported that it is harder to maintain a conversation with his dad because he does not remember things ○ Steve’s other son, Tony, reported that he gets frustrated trying to maintain conversation because his dad needs more time to process

Assessment Findings

• The CLQT assessed Steve’s 5 cognitive domains:

○ Attention: Steve had slight difficulty story retelling and completing mazes and cancellation tasks. ○ Memory: Steve demonstrated anomia, mild reading comprehension skills, and struggled to answer personal facts about himself ○ Language: Steve displayed slight language deficits during story retelling ○ Executive Function: Steve performed well with the clock drawing and symbol cancellation tasks. ○ Visuospatial skills: Steve’s working memory and mental flexibility during the symbol trail tasks showed mild performance

Diagnostic Impressions

• The patient has mild nonaphasic cognitive-communicative deficits due to

his mild traumatic brain injury. Cognitive-communicative deficits include reduced attention and memory, moderate visual spatial deficits, and minimal language impairments. In this context, Steve presents with difficulty maintaining appropriate conversation skills. These include his inability to process linguistic stimuli within a normal time frame and his inability to full express himself due to his anomia.

Treatment Recommendation

• Areas to target:

○ Cognitive-communication deficits ■ Specifically in attention and memory

• Duration/frequency

○ Once a week for 60 minutes ○ Outpatient setting

• Individual sessions are recommended for Steve. Once he shows progress,

the SLP will incorporate group therapy to help him generalize his skills.

EBP Treatment Approaches

Dual Task Training Research shows dual task training improves shifting attention to two separate tasks

• Obstacle crossing:

○ Requires participant to monitor environment and adjust strategies as needed ○ Requires high level of attention ○ Obstacle moves high or low

• Auditory Stroop task

○ During the obstacle crossing, a woman’s voice in a high pitch and a low pitch was used ○ Participants needed to identify the word that was spoken

• Results: indicated that dual-task training needs to be similar to targeted tasks to yield

reliable, positive training outcomes

EB Treatment Approaches & Rationale

Research shows a multidisciplinary approach reduced physical symptoms ○ 2525 soldiers who returned from combat for 3 to 4 months from a one-year deployment to Iraq (Hoge, et. al., 2008). Soldiers experienced a loss of consciousness were also found to have: ○ Post-traumatic stress disorder (PTSD), altered mental status, with other injuries, and with no injury

• A strong correlation was found between mild traumatic brain injury, PTSD, depression,

and physical health symptoms in combat veterans.

• Management of symptom-based disorders and implementation of collaborative care to

mental disorders are important in designing intervention strategies

• Result of treatment for PTSD and depression found those with mild traumatic brain

injury to have reduced physical health symptoms, except for headaches (Hoge, et.al., 2008).

Long Term & Short Term Goals

• LT: Steve will increase cognitive communication skills across various tasks.

○ ST: Steve will retain memory of verbal stimuli with 80% accuracy with minimum cues. ○ ST: Steve will demonstrate alternating attention between 2 stimuli, for 5 minutes with moderate cues.

• LT: Steve and his family will work with the interdisciplinary team to implement

functional communication strategies in order to improve quality of life. ○ ST: Steve and his family will identify and discuss challenging areas of communication. ○ ST: Steve will perceive and interpret others’ behaviors and improve monitoring

• f emotions with 80% accuracy with minimum cues.

Outcome Measures

• Outcome Measures used by Clinician

○ The clinician will monitor progress during sessions by keeping data on the number of correct practice trials and the level of support that is provided (e.g. prompts, cues, etc.) ○ The clinician will monitor progress and generalization by using naturalistic probes within identified naturalistic environments regarding target behaviors.

Selecting Patient-Reported Outcomes Measures: A Committee Update. (2018). Retrieved from https://www.asha.org/Articles/Selecting-Patient-Reported-Outcomes-Measures-/

Outcome Measures-PROs

• PROs (Patient-Reported Outcome Measures)

○ Seek to consider patient’s perspectives on issues that cannot be directly observed by clinician ○ Focus on psychosocial function (e.g. self-efficacy or social roles) ○ Help document outcome of our treatment within health care ○ Generally taken pre-treatment and post-treatment

• Examples

○ ASHA Quality of Communication Life Scale (QCL) ■ Assess impact of communication disorder on relationships; communication with

• thers within a social sphere; participation in work, education, and QOL

○ Quality of Life after Brain Injury (QOLIBRI) ■ Disease-specific health-related quality of life (HRQOL) tool devoted to TBI made up of a multidimensional structure containing 37 items on 4 satisfaction scales “Cognition”, “Self”, Daily Life & Autonomy”, “Relationships”, etc.

Selecting Patient-Reported Outcomes Measures: A Committee Update. (2018). Retrieved from https://www.asha.org/Articles/Selecting-Patient-Reported-Outcomes-Measures-/

Considerations

• The treating SLP will discuss information regarding the case with

multidisciplinary team including: ○ General VA physician, audiologist, neurologist, psychologist, OT, PT

• SLP will continue to monitor this progress in and out of sessions via

communication with family members/ caregivers.

• SLP will play an important role in the multidisciplinary team by

providing education to both family members and medical team regarding SLP’s role and scope of practice regarding cognitive-communicative deficits.

References

Centers for Disease Control and Prevention. (2015). Report to congress on traumatic brain injury in the united states: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury

• Prevention. Atlanta, GA.

Hoge, C. W., McGurk, D., Thomas, L. J., Cox, A. L., Engel, C. C., & Castro, A. C. (2008). Mild traumatic brain injury in u.s. soldiers returning from iraq. The New England Journal of Medicine, 358 (5), 453-463. Kimbarow, M. L. (2016). Cognitive communication disorders. San Diego: Plural Publ. Mittenberg, W., Canyock, E. M., Condit, D., & Patton, C. (2001). Treatment of post-concussion syndrome following mild head injury. Journal of Clinical and Experimental Neuropsychology, 23(6), 829-836. doi:10.1076/jcen.23.6.829.1022 Selecting Patient-Reported Outcomes Measures: A Committee Update. (2018). Retrieved from https://www.asha.org/Articles/Selecting-Patient-Reported-Outcomes-Measures-/ Traumatic brain injury. (2018, January 17). Retrieved from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557 Wordern, T. A & Vallis, L. A. (2018). Examining transfer effects of dual-task training protocols for a complex locomotor task. Journal of Motor Behavior, 50(2), 1940-1027.

Thank you!

Questions?