10/31/17

1

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. DefinetheSLP’sroleonaninterdisciplinaryconcussionteam

3. Identifythreeevidence-basedinterventionsforadultswithconcussions

💥ThinkdifferentlyaboutconcussionandSLP

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).

10/31/17

2

PosttraumaticSymptom-Complex

• “Weeksormonthsaftertheaccident,thepatientwillvoice…headache,impairmentinattentionandconcentration,poormemory,depressionandemotionalinstability,loweredtoleranceoffrustration,sleepdisturbances,lossofsexualdirveandintolerancetoalcohol”(Benton,1979)• “Thereisastrikingdiscrepancybetweenthepresumably‘subjective’complaintsofthepatientandthepresumably‘objective’findingsofthephyscian”(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.

10/31/17

3

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:🍎 Whatisrecovery?🍎 Howisitdetermined?🍎 Isthebrainvulnerable

toincreaseddamagewhencellulardysfunctionispresent?

Returntoactivity• Thomas,Apps,etal(2013)AAP

NationalConference

Standardofcare1-2daysofrest!Confirmedin2015,2016,2017.

William

son

’

sActivityRestrictionModelofDepression

IATROGENICHARMInactivityslowsfunctionalrecoveryandfacilitatesdepression.Cellularchangesremainlongpostfunctionalrecovery.Whowins?

10/31/17

4

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 It’snotjustthehistory

• 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)

•Canada,NZ,Norway,UK,USA•Activedutyservices,Vets,workplace,sports,trauma(MVAs,etc)•Quotesandthemesinterpreted

10/31/17

5

‘Thisisjustacompletelynewme,Idonotrecognizemyself’

“Iwoundupsettling.Iwoundupgoingtoatrailerfactory.Isaidokay.Iwon'tbeabletofinishschool.IguessI’lljustdo…somethingItoldmyselfIwouldneverdo.SoIsettled.Itwasreallyadisappointingfeeling…likeIwasafailure”

“Youcan’treallytalktopeopleaboutbecausetheylookatyouandtheythink“Youlookallright.Youknow,nothingwrongwithyou…PeoplejustexpectedmetobetheexactlyhowIhadalwaysbeenandIwasn’t“

‘IwentthroughallthiscrapforfouryearsandI’mwaitingforsomethinggood…forsomebodytosayokayhere’sasolution’

“I’dbewalkingintotownandI’dhaveabsolutelynoideawhereIwas.I’dforgetwhyI’dgonetotown,whichtownitwas,eventothepointwheremyhousewas.AndinconversationI’dcompletelyforgetwords,completelyforgetsentences“

‘Thelightattheendofthetunnel;that’swhatweareworkingtowards,sowewillgetthere’

InvisibleInjury

StrengthsRemain

AlteredSenseofSelf

ShameGuilt

Embarrassment

ViewedasDamagedorLying

Individuallymodulated Sociallymodulated

ConceptualFrameworkrepresentingthesenseofselfforanindividualwithPPCS

Draft:Hardin,Johnson,&Jones

OtherKeyConsiderations

Oldstersandyoungsters

Specialpopulation:ActiveDuty/Veterans

Cognitivedysfunction

10/31/17

6

Workplaceinjury

BasedonqualitativeworkofMansfieldetal(2015)&Stergiou-Kitaetal(2016)

mTBI problems=SLPproblems

StateoftheStateforSLPsSalvatore&Fjordbak(2011,AJSLP)“…treatmentofconcussionisnottraditionallycoveredingraduateeducationcurriculumforSLPs”(p.2)

ICCDC(Kennedy)mostneurogenicscourseshave1TBIlecture

Knowncog-comm changesinTBI

•Attention•ProcessingSpeed•WorkingMemory•Memory/NewLearning•EFumbrella•SocialCognition

Cognitive

•WordFinding•Auditorycomprehension•Discourse•Conversationalsuccess•Readingcomprehension•Writinggeneration&cohesion

Communication

Knowncog-comm changesinTBI

•Attention•ProcessingSpeed•WorkingMemory•Memory/NewLearning•EFumbrella•SocialCognition

Cognitive

•WordFinding•Auditorycomprehension•Discourse•Conversationalsuccess•Readingcomprehension•Writinggeneration&cohesion

Communication

Physiologic

Physiologic

Knowncog-comm changesinacutemTBI

•Attention•ProcessingSpeed•WorkingMemory•Memory*/NewLearning•EFumbrella•SocialCognition

Cognitive

•WordFinding(slowprocessing)•Auditorycomprehension(AUD)•Discourse(slowprocessing)•Conversationalsuccess(fatigue)•Readingcomprehension(visual)•Writinggeneration&cohesion(fatigue)

Communication

Physiologic

Physiologic

10/31/17

7

Knowncog-comm changesinPPCS

•Attention•ProcessingSpeed•WorkingMemory•Memory/NewLearning•EFumbrella•SocialCognition

Cognitive

•WordFinding(many)•Auditorycomprehension*•Discourse(Tucker&Hanlon,2009,BI)*•Conversational(Sveen,2013,Dis&Reh)*•Readingcomprehension(Sveen etal)*•Writinggeneration&cohesion*

Communication

Psychological

Psychological

AUD

BroadagreementinAUDthatlong-termchangesinaudiofunctionresultfrommTBI….

“Theagreementwithinaudiologyisnotsharedbetweendisciplines”

(Hooveretal,2015,Perspectives p.12)

Neuropsych

CausedbyPTS

CBT

PCS

Diffusedysfunction

Resolvewithsx

AuditoryHypothesis

Physiologicdamage

Decreasedencodingprecision

Hoover,Souza&Gallun,2015,Perspectives

Speech:maybe…yes...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.

10/31/17

8

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

• 93postsin2017on”concussion”• 41onassessment

• 371poststotalinSIG2• 169onassessment

• 43poststhisyearmTBI• 20thisyearonassessment

• 522acrossSIGs

2015ReviewarticleKrug&Turkstra state:“thattherearenodatabasedguidelinesaboutwhattouseandwhen”

TotallyunscientificSIG2skim:

• AlzheimerQuickTest• APT• BRIEF-A• BriefTestofAttention• BNT• CLQT• CELF-4• Conner’sCPT• DKEFS• FAVRES• MOCA

• RAVLT• RIPA-2• SCATBI• SLUMS• STAC• Trails(various)• TEA/TEA-Ch• TLC-E• TVCF(fluency)• Symptomscoremeasures• Woodcock-Johnson

10/31/17

9

Myevaluation:*

• Interview• BRIEF-A• FAVRES2&4(incl.writing)• NeurobehavioralSymptomInventory(NSI)• LaTrobe CommunicationQuestionnaire• Generative&speededconfrontationalnaming(WJIV,COWAT)•WMS-IVLogicalmemoryanddelay;RAVLT• NelsonDennyReadingTest;WJIVReadingComp• King-Devick TestforConcussion;WJIVProcessingSpeedCluster(Dimmette-Schweigert,Fredrickson,&Hardin2016)

•WJIVAuditoryAttentionsubtest(Aud WorkMem)• ForVeterans:SCAN-3screen

NOTNEWNEWS(Coelho,Turkstra,Ylvisaker,Duff,Roth…..)

ANCDSRoles•Definethescopeofthedisorder•Withoutthis,SLPscannotknowwhattoassess.

•Broadlyrecommendmeasures/parameters•Createtoolsformilddysfunction• Individualvariability/vulnerability

“TooEasy”•Helptodefend”WNL”• 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

•Clearlyunderstandbarriersandfacilitators• Staff&bossperceptions• Personalfeelingsofguilt,shame,embarrassment,labeledasincompetent,burden,isolation• Financialimplications•Masculinevs.Feminineworkplaceenvironment

•Providecleareducationtoworkplace•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

10/31/17

10

SymptomManagement

LOUD Resigned Evolve

“Don’tworryaboutthegrocerystore.Focusonthecottagecheese”

DavidHovda

CriticalnextstepsIsee….18moplan

Exploitcurrentenvironments:• Neuroheavyrehabdepartments• InjuryrelatedmTBI• Acutecare– letspeechbethe14dcheckinfromEDvisits• Considerstateassn meetingstoeducate&empower

• PublishsystematicreviewofSLPEB.Spoileralert!

• PublishbroadconsensusstatementSLProle

• Getaseatatthetable

3yearplan

• Definethescopeofcommunicationchangesthroughqualitativework• Systematicallyaddressholesinpediatricknowledgebase• Embracethatconcussionisoneofahostofmilderdisorders– andthesearenotgoingaway

BrennerCoehloDuffGlangHernandezHovdaJonesKennedyKellyKrupaSohlbergRamsbergerRoth

&Lyn

Thankyouall!Iwouldn'tbeupherewithoutyou.