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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. 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).
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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.
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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:🍎 Whatisrecovery?🍎 Howisitdetermined?🍎 Isthebrainvulnerable
toincreaseddamagewhencellulardysfunctionispresent?
Returntoactivity• Thomas,Apps,etal(2013)AAP
NationalConference
Standardofcare1-2daysofrest!Confirmedin2015,2016,2017.
William
son
’
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 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
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‘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
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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
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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.
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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
• 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
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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
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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.
