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

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Page 1: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Individualized�Management�and�Treatment�Following�Traumatic�Brain�Injury

Jami�Skarda,�M.S.,�CCCͲSLPWarrior�Recovery�Center,�Fort�Carson,�CO

Disclaimer

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�cognitiveͲcommunication�deficits�associated�with�concussion�and�traumatic�brain�injury

• Apply�treatment�techniques�for�cognitiveͲcommunication�deficits

• Recognize�his/her�role�in�educating�others�regarding�concussion�and�traumatic�brain�injury

Page 2: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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“Sometimes�I�feel�lost�in�a�storm,�waiting�for�a�break�in�the�clouds…”

DefinitionA�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)• PostͲtraumatic�amnesia�(PTA)• Alteration�of�Consciousness�(AOC)• Neurological�deficits�that�may�or�may�not�be�temporary

• Intracranial�lesion

www.dvbic.dcoe.mil (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)

Page 3: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Severity�Determination

• Glasgow�Coma�Scale�(GCS)

www.cdc.gov/traumaticbraininjury/severe.html

Severity GCS

Mild 13Ͳ15

Moderate 9Ͳ12

Severe 3Ͳ8

Traumatic�Brain�Injury

• 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

Centers�for�Disease�Control�and�Prevention�(2015).

Leading�Causes�of�TBI

Falls35%

MVA17%

Struck17%

Assualts10%

Unknown21%

Centers�for�Disease�Control�and�Prevention�(2014)

Page 4: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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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

• SelfͲreports�indicate�15Ͳ20%�of�those�have�sustained�mTBI

• True�numbers�remain�unknown

CornisͲPop�et�al.�(2012)

Page 5: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Are�Blast�Related�TBI’s�Different?

• No�cognitive�differences

• Increased�incidence�of�comorbidities

• Research�is�working�to�determine�cellular�changes

Screening�Tools• Acute�Concussion�Evaluation

• Concussion�in�Sports�Palm�Card

• Military�Acute�Concussion�Examination

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

Page 6: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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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

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�

Page 7: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Normal�Course�of�Recovery

• Most�individuals�resolve�symptoms�within�two�weeks

• Follow�Return�to�Activity�and�Physician�recommendations

• PostͲtraumatic�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�nonͲstandardized�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

Page 8: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Assessment

• Standardized�and�NonͲStandardized�Assessment�Tools– Acute�or�Chronic

– Clinical�setting

–What�assessment�procedures�will�best�capture�the�patient?

Assessment

• Standardized�Assessments– Functional�Assessment�of�Verbal�Reasoning�and�Executive�Strategies�(FAVRES)

–Woodcock�Johnson�IV

Assessment

• Assessment�of�cognitiveͲcommunication�challenges�in�Service�Members�and�Veterans– Presence�of�comorbidities– Issues�to�realͲlife�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

Page 9: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Treatment

• Motivate�the�patient

• Clinician�Developed�Goals

• Patient�Developed�Goals

• Educate�Family

Treatment

• Mindful�of�personal�factors

• PreͲinjury�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

(CornisͲPop,�et�al.)

Treatment

• Symptomatic�Intervention

• Train�compensatory�and�metacognitive�strategies�

• Treatment�should�be�embedded�into�meaningful�contexts�individualized�to�patient

• Instill�Confidence�in�his/her�skills�

Page 10: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Treatment• Recovery�from�combatͲrelated�concussion/mTBIcan�be�complicated– Physically�and�emotionally�traumatic�circumstances

– Potentially�repetitive�cumulative�nature�of�concussions�sustained�over�a�tour

– Comorbidities

– Difficulty�following�postͲconcussion�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• 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

– LevelͲ1�Patient�performs�somewhat�less�than�expected

– LevelͲ2�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.

Ͳ1 I�currently�utilize�my�daily�planner, to�improve�my�function,�only�when�provided�cues�from�others.

Ͳ2 I�will�not�utilize�my�daily�planner.

Lewis,�Dell,�Matthews.

Treatment• 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

Page 11: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Strategies

• Cognitive�Strategies–Memory�Strategies

– Attention�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

Page 12: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Memory

• Memory�Tasks– Recall�information�from�item�read– Recall�instructions– Recall�conversations– ToͲdo’s–Weapon�System– Education– Child’s�school�schedule– Routes/directions

Attention�Strategies

• Attention�Strategies– Awareness�of�attention�limits– SelfͲtalk– 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�multipleͲstep�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

Executive�Functions

• Strategies– Slow�Down

– External�Supports

– Self�and�Situational�Awareness

– Start�all�tasks�with�the�End�Goal�in�Mind

Page 13: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Executive�Functions

• During�a�task�have�patient�follow1. 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. Start5. 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�

– SetͲup�Time�Checks

Page 14: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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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�SelfͲAwareness

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

Page 15: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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Pragmatic�LanguageSymptoms Reaction/Response Management�of�

SymptomsPositive�Outcomes�

of�Reaction/Response

Negative�Outcomes�of�

Reaction/Response

What�I�will�do�different�next�time

Cognitive:

Behavioral:

Emotional:

Physical:

Fluency

• Fluency�Disorders– Not�typical�symptom�of�concussion�or�mTBI

– Increased�incidence�of�fluency�referrals�for�service�members�and�veterans

– 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

Group�Treatment

• iROC– SLP– Occupational�Therapy– Behavioral�Health– Creative�Media– Physical�Activity– Education

Page 16: Disclaimer Individualized Management · 1 Individualized Management and Treatment Following Traumatic Brain Injury Jami Skarda, M.S., CCC rSLP Warrior Recovery Center, Fort Carson,

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“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

ReferencesBrown,�Mannix,�et�al. Effect�of�Cognitive�Activity�Level�on�Duration�of�PostͲConcussion�Symptoms. Journal�of�the�American�Academy�of�Pediatrics, 2014.�Web.��20�Mar.�2015.�

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.�2015.

ͲͲͲ.�Get�the�Stats�on�Traumatic�Brain�Injury�in�the�United�States.�2010.�Web.�27�Mar.�2015�

Cicerone,�Dahlberg,�Kalmar,�et�al. “EvidenceͲBased�Cognitive�Rehabilitation:�Recommendations�for�Clinical�Practice.” Archives�of�Physical�Medicine�and�Rehabilitation�81.12�(2000):�1596Ͳ1615.�Print.�

CornisͲPop,�Mashima,�et�al.�“CognitiveͲcommunication�Rehabilitation�for�CombatͲrelated�Mild�Traumatic�Brain�Injury”�The�Journal�of�Rehabilitation�Research�and�Development�JRRD 49.7�(2012);�xiͲxxv.�Web.�

Defense�and�Veterans�Brain�Injury�Center. DoDWorldwide�Numbers�for�TBI�Worldwide�Totals.�2014. Web.�March�2015.�

Gessel,�Fields,�et�al.�“Concussions�Among�United�States�High�School�and�Collegiate�Athletes.”�Journal�of�Athletic�Training�42.4�(2007):�459Ͳ503.�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):�403Ͳ409).�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):�56Ͳ67.�Print.

Ryu,�Jiwon,�Iren�HorkayneͲSzakaly,�et�al.�"The�Problem�of�Axonal�Injury�in�the�Brains�of�Veterans�with�Histories�of�Blast�Exposure." Acta NeuropathologicaCommunications.�BioMed Central,�n.d. Web.�26�Mar.�2015.

Tsaousides,�Theodore,�and�Gordon,�Wayne.�“Cognitive�Rehabilitation�Following�Traumatic�Brain�Injury:�Assessment�to�Treatment.”�Mount�Sinai�Journal�of�Medicine 76�(2009):�173Ͳ181.�Print.�