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Download Evaluation and Treatment for Post Concussive Syndrome
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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 Older adolescents aged 15 to 19 years Older adults aged 65+ years Adults aged 75 years and older have the highest rates of TBI-related hospitalization Definition of “Concussion” “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” Direct or indirect blow, impulsive force to head Rapid onset & short duration of s/s, spontaneous resolution of s/s Functional disturbances rather than structural 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 Confusion (unsure of game, score, or opponent) Headache ( most common symptom; 93%) Balance problems or dizziness Double vision Pain with looking at bright light Ringing in the ears Feeling sluggish or slowed down Feeling foggy or groggy Does not “feel right” Uncoordinated movements (stumbling) Unable to recall words that were just spoken to them 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 Past neurological history (migraine, seizure, CVA, prior concussions) Current Medications Support Structure & home environment Work & family roles Evaluation: Sport Concussion Assessment Tool Objective measure to rank symptoms Uses Likert scale to rate severity of symptoms Symptom Scores ranging from 0 to 22 Severity Score from 0 to 132 Evaluation: IADLS Financial Management Complex Home Management Tasks Child Care Work Evaluation: Cognition Screening Tools Montreal Cognitive Assessment (MoCA) St. Louis University Mental Status (SLUMS) Trails A & B Clock Drawing Allen Cognitive Level Screen Evaluation: Cognition Focus on Functional Complaints Look for clusters Consider working memory, processing speed, pace, need for recheck, double check, loss of confidence Anxiety management Evaluation: Vision Subjective Visual History Prescription lens use History of Eye Surgery , other conditions Screen Time Reading Tolerance Evaluation: Vision Objective Acuity Oculomotor Tracking/Smooth Pursuits Saccades Convergence/Divergence Normal 2-3inches Near/Far Visual Scanning Sheets Brain Injury Visual Assessment Battery Evaluation: Vision Objective Vestibular Screen Vestibular Ocular Reflex (VOR) Dynamic Visual Acuity Analyzing the Environment Auditory and Visual Environment Intensity Amount Competing Stimuli Predictability Intervention: Environmental Modifications Strategies to eliminate provocative stimulus for symptom management Sunglasses Earplugs Scheduled rest breaks 5-10 minutes removing self from environment Alter Lighting Encourage graded exposure based on symptoms resolution Intervention: Adaptive Approach to Oculomotor Skills Line blocking or Typoscope Increasing visual contrast Yellow acetate paper overlay to darken words Glare Glasses or Tinted Lenses Screen Filter Use of “f.lux” or decreasing computer backlighting Intervention: Remedial Approach to Oculomotor Skills Fixation Maintaining focus on target without distraction Pursuits Following targets: Ball around Frisbee, swinging ball, laser pointer Mazes Scanning sheets Saccades Switching targets at various distances Switching lines, reading columns, connecting dots Wide search/Environmental Search Convergence Pencil Pushups: Bringing object toward face until double image, just prior to double image holding gaze and returning to start position Brock String: Three beads placed at various distances on string to promote visual focus on object at various distances Intervention: Adaptive Approach to Cognition Start with low tech options with good visual support Education around fatigue and anxiety Education on memory loop Decrease Cognitive Load and environmental press Paradigm Shift Intervention: Remedial Approach to Cognition 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 Job Specific Outline Job Tasks Initial adaptation plan Gradual increase over months Highly motivated to return offers opportunities for set backs Consider underlying cause for resisting return to work Interdisciplinary Roles Physical Therapy Speech Therapy Return to Play Return to Learn Balke: Autonomic regulation Cognitive Linguistic Deficits: Vestibular Ocular Reflex (VOR) Attention Vestibular Dysfunction (Vertigo) Processing Speed Dynamic Visual Acuity – Gaze stabilization 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 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.
