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10/31/17
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ConcussionandSLP:TheStateoftheStateKathrynHardin,MACCC-SLP,CBIST
UniversityofColoradoSchoolofMedicine
Disclosures
Financial: Ms.HardinisasalariedfacultymemberattheUniversityofColoradoSchoolofMedicine.HerworkattheMarcusInstituteforBrainHealthisprivatelyfundedthroughagiftfromtheMarcusFoundationtotheUniversityofColorado.
SheisalsopaidasaGraduateFacultyFellowintheDepartmentofSpeech,Language&HearingSciencesattheUniversityofColorado-Boulder.Shereceiveshonorariaforworkshopsandpresentationsnationallyandinternationally.
ShehasreceivedawaiverofherANCDSconferencefeeandanhonorariumfromANCDSforherpresentationatthismeeting.
Non-financial: Ms.HardinisattimesareviewerforvariousASHAcommitteesrelatedtoTBI.
LearningObjectives
1. Identifythreefactorsinassessingcausalityandmodifiersinconcussion
2. DefinetheSLPâsroleonaninterdisciplinaryconcussionteam
3. Identifythreeevidence-basedinterventionsforadultswithconcussions
đĽThinkdifferentlyaboutconcussionandSLP
Planfortheday
⢠Briefoverviewofconcussion/mTBI⢠SystemicproblemsinmTBI⢠SLPspecificconsiderations
⢠Nextsteps
Concussionmanagementchallenges
Highlyindividual
RapidlychangingEB
Previousmisinfo
Variableworkenvt
NewSLProle
Sportrelatedconcussionisatraumaticbraininjuryinducedbybiomechanicalforces.
⢠Maybecausedeitherbyadirectblowtothehead,face,neckorelsewhereonthebodywithanimpulsiveforcetransmittedtothehead.
⢠Typicallyresultsintherapidonsetofshort-livedimpairmentofneurologicalfunctionthatresolvesspontaneously.However,insomecases,signsandsymptomsevolveoveranumberofminutestohours.
⢠Mayresultinneuropathologicalchanges,buttheacuteclinicalsignsandsymptomslargelyreflectafunctionaldisturbanceratherthanastructuralinjuryand,assuch,noabnormalityisseenonstandardstructuralneuroimagingstudies.
⢠Resultsinarangeofclinicalsignsandsymptomsthatmayormaynotinvolvelossofconsciousness.Resolutionoftheclinicalandcognitivefeaturestypicallyfollowsasequentialcourse.However,insomecasessymptomsmaybeprolonged.
⢠Cannotbeaccountedforbyothercircumstances.
2016Berlindefinitionsport-relatedconcussion(McCroryetal2017)
Newestconsensusinfo:BritishJournalofSportsMedicine(Apr2017).
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PosttraumaticSymptom-Complex
⢠âWeeksormonthsaftertheaccident,thepatientwillvoiceâŚheadache,impairmentinattentionandconcentration,poormemory,depressionandemotionalinstability,loweredtoleranceoffrustration,sleepdisturbances,lossofsexualdirveandintolerancetoalcoholâ(Benton,1979)⢠âThereisastrikingdiscrepancybetweenthepresumablyâsubjectiveâcomplaintsofthepatientandthepresumablyâobjectiveâfindingsofthephyscianâ(Benton,1989)
⢠Historicalconcernsofmalingering
⢠Toomuch⢠Toolittle
⢠Ineffective
⢠Lability⢠Frustration⢠Anxiety⢠Depression
⢠CognitiveOverwhelm⢠ProcessingSpeed⢠Memory/Learning
⢠ExecutiveFunct⢠Attention
⢠WordFinding
⢠Headache⢠Pain⢠Sensitivities⢠Fatigue⢠Vision⢠Balance
Physical Cognition
SleepEmotion
Commonchangesafterconcussion
Concussion/Uncomplicated
⢠Changeinneurostatus
⢠Nostructuralfindings
⢠Mildest&mostcommonTBI
⢠Mostresolvequickly
ComplicatedmTBI
⢠Presentslikeconcussion,butwith+imagingfindings
⢠Recoveryistypicallylonger
Post-Concussivesyndrome
⢠Definitioniswidelyvariable
⢠Symptomslingerlongerthanexpected
⢠10-30%⢠Commonco-occurringchangesinPH
Silverberg,Lange&Iverson,2016 ,Rose,Fischer&Heyer,2015
?
SportsMed Athl
Train
Engineering
Neurosci
NeuroPsych
PsychiatryNeurol
ogy
Neurosurg
NeuroOpth
PT
Pediatrics
Epidem
Concussion Evidence Base
Neurom
etabolicCascade-G
iza&Hovda,200
1;
Journa
lAthleticTraining
Cellularphysiology Functionalimagingchangespresent
⢠Welldocumentedfunctionalimagingchangesin:fMRI,DTI,SPECT,PET,andEEG
⢠Despite physiologicalchanges:Nobehavioralgoldstandardforassessment.Sx self-reportrequired.
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Keightley,M,Saluja,SR,Chen,JKetal,(2014)Jrnl ofNeurotrauma
Behavioralrecoveryfromconcussionistakinglongerforindividualsacrossages(thanpreviouslythought)⢠Adults:Kolias,etal,(2013).PracticalNeurology.⢠Adolescents:/ChildrenGuerriero etal,2015⢠11-22yo:Eisenbergetal,2014Pediatrics⢠Children:Grubenhoff etal,2014Pediatrics
Foodforthought:đ Whatisrecovery?đ Howisitdetermined?đ Isthebrainvulnerable
toincreaseddamagewhencellulardysfunctionispresent?
Returntoactivity⢠Thomas,Apps,etal(2013)AAP
NationalConference
Standardofcare1-2daysofrest!Confirmedin2015,2016,2017.
William
son
â
sActivityRestrictionModelofDepression
IATROGENICHARMInactivityslowsfunctionalrecoveryandfacilitatesdepression.Cellularchangesremainlongpostfunctionalrecovery.Whowins?
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History
PreviousTBI/Protractedrecovery Learning
Disabilities& ADHD
*Migraineheadache
FemaleSleep
disorder
Trauma/Psychosocialconcerns
Lowereducation,cognition,
SES
Gioia &Lovelll;Nordstrometal2013Riskfactors(mod
ifiers)fo
rconcussio
n&slow
edre
covery Itâsnotjustthehistory
⢠Presentation⢠EarlyCare⢠Existingconcussionknowledgebase
Bigdataanswers,bigdataproblems
⢠CareConsortium(NCAA/DoD;McAllister,McCrea,Broglio,etal)⢠TRACK-TBI(Manleyetal)⢠NationalHighSchoolSports-RelatedInjurySurveillanceStudy (Comstock)
EpidemiologyConditionmodifiersPreventionmeasuresPublicexposuretomTBI
Changingdefinitionmid-studyChanging/absentguidelinesD&IPossibleoldertoolsfordataGeneralizationproblemLossofindividualdifferencesDecreasein$$mod-severeSLPwho?
Qualitativeworkinconcussion
⢠PaucityresearchinmTBI Metasynthesis usedinTBIofmixedseverities⢠AdultsexperienceinTBI(Levack etal,2010,Dis&Rehab)⢠Parentperspectivere:RTS(Andersonetal,2016,BrainInjury)
Differentseverities=differentprofiles(Sherer etal,2015,RehabPsych)
QualitativeMetasynthesis (Hardin,Johnson&Jones,inprep)
⢠ExaminingsenseofselfinadultsPPCS⢠10studiesretainedandevaluatedforqualityusingMcMastertool(Lettsetal,2007)
â˘Canada,NZ,Norway,UK,USAâ˘Activedutyservices,Vets,workplace,sports,trauma(MVAs,etc)â˘Quotesandthemesinterpreted
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âThisisjustacompletelynewme,Idonotrecognizemyselfâ
âIwoundupsettling.Iwoundupgoingtoatrailerfactory.Isaidokay.Iwon'tbeabletofinishschool.IguessIâlljustdoâŚsomethingItoldmyselfIwouldneverdo.SoIsettled.ItwasreallyadisappointingfeelingâŚlikeIwasafailureâ
âYoucanâtreallytalktopeopleaboutbecausetheylookatyouandtheythinkâYoulookallright.Youknow,nothingwrongwithyouâŚPeoplejustexpectedmetobetheexactlyhowIhadalwaysbeenandIwasnâtâ
âIwentthroughallthiscrapforfouryearsandIâmwaitingforsomethinggoodâŚforsomebodytosayokayhereâsasolutionâ
âIâdbewalkingintotownandIâdhaveabsolutelynoideawhereIwas.IâdforgetwhyIâdgonetotown,whichtownitwas,eventothepointwheremyhousewas.AndinconversationIâdcompletelyforgetwords,completelyforgetsentencesâ
âThelightattheendofthetunnel;thatâswhatweareworkingtowards,sowewillgetthereâ
InvisibleInjury
StrengthsRemain
AlteredSenseofSelf
ShameGuilt
Embarrassment
ViewedasDamagedorLying
Individuallymodulated Sociallymodulated
ConceptualFrameworkrepresentingthesenseofselfforanindividualwithPPCS
Draft:Hardin,Johnson,&Jones
OtherKeyConsiderations
Oldstersandyoungsters
Specialpopulation:ActiveDuty/Veterans
Cognitivedysfunction
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Workplaceinjury
BasedonqualitativeworkofMansfieldetal(2015)&Stergiou-Kitaetal(2016)
mTBI problems=SLPproblems
StateoftheStateforSLPsSalvatore&Fjordbak(2011,AJSLP)ââŚtreatmentofconcussionisnottraditionallycoveredingraduateeducationcurriculumforSLPsâ(p.2)
ICCDC(Kennedy)mostneurogenicscourseshave1TBIlecture
Knowncog-comm changesinTBI
â˘Attentionâ˘ProcessingSpeedâ˘WorkingMemoryâ˘Memory/NewLearningâ˘EFumbrellaâ˘SocialCognition
Cognitive
â˘WordFindingâ˘Auditorycomprehensionâ˘Discourseâ˘Conversationalsuccessâ˘Readingcomprehensionâ˘Writinggeneration&cohesion
Communication
Knowncog-comm changesinTBI
â˘Attentionâ˘ProcessingSpeedâ˘WorkingMemoryâ˘Memory/NewLearningâ˘EFumbrellaâ˘SocialCognition
Cognitive
â˘WordFindingâ˘Auditorycomprehensionâ˘Discourseâ˘Conversationalsuccessâ˘Readingcomprehensionâ˘Writinggeneration&cohesion
Communication
Physiologic
Physiologic
Knowncog-comm changesinacutemTBI
â˘Attentionâ˘ProcessingSpeedâ˘WorkingMemoryâ˘Memory*/NewLearningâ˘EFumbrellaâ˘SocialCognition
Cognitive
â˘WordFinding(slowprocessing)â˘Auditorycomprehension(AUD)â˘Discourse(slowprocessing)â˘Conversationalsuccess(fatigue)â˘Readingcomprehension(visual)â˘Writinggeneration&cohesion(fatigue)
Communication
Physiologic
Physiologic
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Knowncog-comm changesinPPCS
â˘Attentionâ˘ProcessingSpeedâ˘WorkingMemoryâ˘Memory/NewLearningâ˘EFumbrellaâ˘SocialCognition
Cognitive
â˘WordFinding(many)â˘Auditorycomprehension*â˘Discourse(Tucker&Hanlon,2009,BI)*â˘Conversational(Sveen,2013,Dis&Reh)*â˘Readingcomprehension(Sveen etal)*â˘Writinggeneration&cohesion*
Communication
Psychological
Psychological
AUD
BroadagreementinAUDthatlong-termchangesinaudiofunctionresultfrommTBIâŚ.
âTheagreementwithinaudiologyisnotsharedbetweendisciplinesâ
(Hooveretal,2015,Perspectives p.12)
Neuropsych
CausedbyPTS
CBT
PCS
Diffusedysfunction
Resolvewithsx
AuditoryHypothesis
Physiologicdamage
Decreasedencodingprecision
Hoover,Souza&Gallun,2015,Perspectives
Speech:maybeâŚyes...no...temporality?
⢠Reported:⢠Dysarthria⢠Dysfluencyreported⢠Psychogenicstuttering(Mattingly,2015,MilitaryMedicine)
⢠DDKrates:mixedresults⢠Poellabauer etal,2015,IEEE⢠Pfieffer-Lapid,Sadagopan &Hardin⢠Dataqualitypoor
⢠Speechrate:Kuruvilla etal,2007BI(ns)⢠2017ASHAtalks:⢠Banksetal:IDofindividualswithmTBIusingvoiceanalysis
SocialCommunication ⢠MacLennan,Picon,Isaki,Cornis-Pop,Mashima,Eshel,Roth,Hammond,Goo-Yoshino,Singson,Frank,Kennedy,Turkstra,Norman,Sohlberg
SLPshavenoconcussionpracticeguidelinesoutsideofmilitarymedicine.
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ConfusionoverRoles&Responsibilities
AcuteCare Subacute >6mos Remotehistory
ConfusionoverRoles&Responsibilities
AcuteCare Subacute >6mos Remotehistory
School-basedSLP
Out-patientMedical
AcuteCarePractitioner
PrivatePractice
LongTermCare
Duff(2009Leader;2015BrainInjury)Salvatore&Fjordbak (2011AJMSLP;2014Persp)Knollman Porteretal(2014,AJSLP)Hardin(2015,Leader)Sohlberg &Ledbetter(2016,AJSLP)Dachtyl &Morales(2017,AJSLP)Ketchem etal(2017,CurRes:Concussion)
AssessmentinSLP
2002 Medically Based 2015 School based*71% RIPA 17.5% CELF53% BDAE 5.5% CASL41% BostonNaming
Test4.3% EOWVT
33% SCATBI 3.4% TestAud Proc Skills27% BriefTestofHead
Injury3.1% PPVT
26% RICEvaluationforRHD
2.8% ROWVT
25% WAB 2.5% TOLD
Duff,Proctor,&Haley(2002);Duff&Stuck(2015)
SIG2Queries
⢠93postsin2017onâconcussionâ⢠41onassessment
⢠371poststotalinSIG2⢠169onassessment
⢠43poststhisyearmTBI⢠20thisyearonassessment
⢠522acrossSIGs
2015ReviewarticleKrug&Turkstra state:âthattherearenodatabasedguidelinesaboutwhattouseandwhenâ
TotallyunscientificSIG2skim:
⢠AlzheimerQuickTest⢠APT⢠BRIEF-A⢠BriefTestofAttention⢠BNT⢠CLQT⢠CELF-4⢠ConnerâsCPT⢠DKEFS⢠FAVRES⢠MOCA
⢠RAVLT⢠RIPA-2⢠SCATBI⢠SLUMS⢠STAC⢠Trails(various)⢠TEA/TEA-Ch⢠TLC-E⢠TVCF(fluency)⢠Symptomscoremeasures⢠Woodcock-Johnson
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Myevaluation:*
⢠Interview⢠BRIEF-A⢠FAVRES2&4(incl.writing)⢠NeurobehavioralSymptomInventory(NSI)⢠LaTrobe CommunicationQuestionnaire⢠Generative&speededconfrontationalnaming(WJIV,COWAT)â˘WMS-IVLogicalmemoryanddelay;RAVLT⢠NelsonDennyReadingTest;WJIVReadingComp⢠King-Devick TestforConcussion;WJIVProcessingSpeedCluster(Dimmette-Schweigert,Fredrickson,&Hardin2016)
â˘WJIVAuditoryAttentionsubtest(Aud WorkMem)⢠ForVeterans:SCAN-3screen
NOTNEWNEWS(Coelho,Turkstra,Ylvisaker,Duff,RothâŚ..)
ANCDSRolesâ˘Definethescopeofthedisorderâ˘Withoutthis,SLPscannotknowwhattoassess.
â˘Broadlyrecommendmeasures/parametersâ˘Createtoolsformilddysfunction⢠Individualvariability/vulnerability
âTooEasyââ˘HelptodefendâWNLâ⢠Facilitateusingbetterassessmenttools⢠Resources?⢠Education?⢠Pooroptionsinthe
speechcloset?⢠Institutionalpushback?⢠Neuropsych/OT
concerns?
Interventionconsiderations
⢠VA/DoDpracticeguidelines(workgroupinclPicon,2016)⢠Careintegratingcognitive,emotionalandinterpersonalskills⢠Metacognitivestrategyinstruction⢠Compensatorytechniquesandaids⢠(VA/DoDincl Picon,2016)
⢠Cornis-Popetal(2012,JRRD)⢠Workinterdisciplinarily⢠Individualizedtreatmentapproaches⢠TherapeuticAlliance⢠AttentiontrainingwithMSI⢠Treatwhatyousee
Work:Beyondaccommodations
â˘Clearlyunderstandbarriersandfacilitators⢠Staff&bossperceptions⢠Personalfeelingsofguilt,shame,embarrassment,labeledasincompetent,burden,isolation⢠Financialimplicationsâ˘Masculinevs.Feminineworkplaceenvironment
â˘Providecleareducationtoworkplaceâ˘Validatewhateverishastakensofar
PerStergiou-Kitaetal(2016)&Mansfieldetal(2015)
Wheredowefitinterdisciplinarily?
⢠Dependsonthetimelineandthepatient⢠NotallptsneedSLP!
⢠Vargo etal(2015,PM&R)⢠Referralsfrommultidis concussionclinicevaluatedrestrospectively.1SportsMD,1TBIMD⢠PTandSLPratesalmostequivocal(43%forSLP)⢠SLPwastypicallyreferredinternally⢠Highestrateofwomenreferred⢠STslowestmeanreferraltime⢠Sometimesonlysentforcomputerizedretest
Ourteam
Patient
InternalMed
Neurology
SleepNeurology
NeuroRadiology
PT
SLPNeuroPsych
Counseling
CaseManager
T-Rec
ClinicalPharmacy
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SymptomManagement
LOUD Resigned Evolve
âDonâtworryaboutthegrocerystore.Focusonthecottagecheeseâ
DavidHovda
CriticalnextstepsIseeâŚ.18moplan
Exploitcurrentenvironments:⢠Neuroheavyrehabdepartments⢠InjuryrelatedmTBI⢠Acutecareâ letspeechbethe14dcheckinfromEDvisits⢠Considerstateassn meetingstoeducate&empower
⢠PublishsystematicreviewofSLPEB.Spoileralert!
⢠PublishbroadconsensusstatementSLProle
⢠Getaseatatthetable
3yearplan
⢠Definethescopeofcommunicationchangesthroughqualitativework⢠Systematicallyaddressholesinpediatricknowledgebase⢠Embracethatconcussionisoneofahostofmilderdisordersâ andthesearenotgoingaway
BrennerCoehloDuffGlangHernandezHovdaJonesKennedyKellyKrupaSohlbergRamsbergerRoth
&Lyn
Thankyouall!Iwouldn'tbeupherewithoutyou.
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