Speech Therapy post Concussion - the Brain Injury Alliance of New

Suzanne W. Kutsmeda, MS, CCC-SLP
Concussion Overview
 Concussion is a brain injury and is defined as a
complex pathophysiological process affecting the
brain, induced by biomechanical forces. Several
common features that incorporate clinical, pathologic
and biomechanical injury constructs that may be
utilized in defining the nature of a concussive head
injury include:
Consensus Statement on Concussion in Sport, Zurich International Conference 2012
Concussion continued:
 Concussion may be caused either by a direct blow to the head, face,
neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to
the head.
 Concussion typically results in the rapid onset of short-lived
impairment of neurological function that resolves spontaneously.
However, in some cases, symptoms and signs may evolve over a number
of minutes to hours.
 Concussion may result in neuropathological changes, but the acute
clinical symptoms largely reflect a functional disturbance rather than a
structural injury and, as such, no abnormality is seen on standard
structural neuroimaging studies.
 Concussion results in a graded set of clinical symptoms that may or
may not involve loss of consciousness. Resolution of the clinical and
cognitive symptoms typically follows a sequential course. However, it is
important to note that in some cases symptoms may be prolonged.
Consensus Statement on Concussion in Sport, Zurich International Conference 2012
Common Symptoms:
 Headache or a feeling of











pressure in the head
Temporary loss of consciousness
Confusion or feeling as if in a fog
Amnesia surrounding the
traumatic event
Dizziness or "seeing stars"
Ringing in the ears
Nausea
Vomiting
Slurred speech
Delayed response to questions
Appearing dazed
Fatigue
 Concentration and memory





complaints
Irritability and other personality
changes
Sensitivity to light and noise
Sleep disturbances
Psychological adjustment
problems and depression
Disorders of taste and smell
Symptoms common to young children:
 Appearing dazed
 Listlessness and tiring easily
 Irritability and crankiness
 Loss of balance and unsteady walking
 Crying excessively
 Change in eating or sleeping patterns
 Lack of interest in favorite toys
Who is part of the Post concussion
team?
 The most effective way to help a child who has sustained a concussion is with a
team approach
 The Student/Child/Athlete
 The Parents/ Caregivers
 The Primary Care provider
 The concussion specialist (neurologist, physiatrist, orthopedist)
 The Neuro-psychologist
 The Opthamologist/Optometrist
 The PT
 The OT
 The School Nurse
 The Special Ed. Director
 The Teachers
 The Guidance Counselor
 The Athletic Director/Trainer
 THE SPEECH PATHOLOGIST
Referrals to speech
therapy
Most common referral
sources are:
 NeuroPsychologist
 Concussion
specialists
Why do I need Speech Therapy?
“ Why do I need this (speech therapy)? I talk just fine!”
-Casey 17 year old patient
“SLP’s can help bride the gap between the medical and educational
models for children with TBI. Although “cognitive
rehabilitation” may not be a term used in IEP or 504 plans,
cognitive communication rehabilitation treatment strategies can
be incorporated into students’ education plans. Speech
Pathologists can contribute to an educational program in several
ways:
SLPs often devise compensatory strategies for executive functions
and memory, such as notebooks and organizers.
Training in Language development and assessment and treatment
of language disorders is a specialty in our field. Children and
teens with TBI need a comprehensive assessment of their
language and literacy skills following an injury. They are most
likely to benefit this type of assessment when they return to
school”.
Assessment
 Pediatric assessment Tools:












Health and Behavior Inventory
Post Concussion Symptom Inventory
Pediatric test of Brain Injury
Continuous Performance Test
Behavior Rating Inventory of Executive Functions (BRIEF)
Test of Everyday Attention for Children (TEACh)
California Verbal Learning Test
Rivermead Post Conussive Symptom Questionnaire
Neurobehavioral Symptom Inventory
Test of Everyday Attention
Dysexecutive Questionaire
Motivated Strategies for Learning Questionaire
Supplemental Assessment:
 Functional Age Appropriate Reading Task
 Confrontational Naming Task Timed/Untimed
 Verbal Description Task
 Navigation with a smart phone/ computer
 Visual Memory Task
 Auditory Memory Task
 Serial subtraction tasks
 Familiar series backwards task
Treatment
 Speech therapy that focuses on cognitive
communication skills is typically covered by insurance
companies
 Lasts between 8-16 weeks
The Evidence
There is a strong evidence base with empirical evidence
to support assessment and treatment strategies for:
 Executive function impairments
 Memory
 Attention
 Social communication
Interventions meet criteria for high quality evidenced
based systematic review:

cognitive – communication
 language skills
 motor speech skills
 swallowing
ASHA National Center for Evidence Based Practice
Target Areas for Treatment
Common Deficit areas
 Receptive Language
 Auditory and Reading Comprehension
 Following multi-step directions
 Understanding abstract language
 Expressive Language
 Verbal Fluency
 Flexible word use
 Topic Maintenance
 Word Finding
 Memory:
 Working
 Short term
 Organization
Receptive Language Skills
 Auditory and Reading Comprehension
 Following Multi-step Directions
 Understanding Abstract Langauge
Expressive Language Skills
 Word Finding
 Verbal Fluency
 Flexible Word Use
 Topic Maintainance
Memory,
Organization , and
Attention
Memory Strategy training for
the treatment of mild memory
impairments from TBI:
Internal strategies
external memory
compensations
Cognitive Rehabilitation Manual, Translating Evidence Based
Recommendations into Practice, 2012
PQRST
 PREVIEW: Preview the Information to be recalled
 QUESTION: Ask Key questions about the text (“what
is the main idea?”)
 READ: Read the material carefully
 STATE: State the answers and if necessary read again
until you are able to answer the questions. Encourage
students to summarize in their own words
 TEST: Test regularly for retention of the information
Attention
Recommend remediation off attentions during Post-Acute rehab.
Direct Attention Training
Strategy Training
Cognitive Rehabilitation Manual, Translating Evidence Based Recommendations into Practice, 2012
Team Approach
Throughout speech therapy it is important to maintain a
team approach and be in contact with:
 Referring Doctors
 Pediatrician
 Concussion Specialist
 Neuro-psychologist
 School Professionals
 Recommendations to parents
 Guidance Counselor
Help!! They aren’t following my
504
 Reiterating recommendations that have been made by
the students doctors
 Problem solving
 Encouraging parent involvement
 Encouraging student to take ownership of
accommodations
Discharge
 Learning and demonstrating use and understanding of
strategies
 Increased function in an academic and social
environment
 Recommend follow up re-evaluation in 3-6 months
 if difficulties continue
 other strategies are needed
 New symptoms arise
Bibliography













www.asha.org
Babcock, Lynn; Byczkowski Terri Wade Shari L.; Ho Mona; Mookerjee Sohug; Bazarian Jeffrey J. (2013). “Predicting
Postconcussion Syndrome After Mild Traumatic Brain Injury in Children and Adolescents Who Present to the
Emergency Department” JAMA Pediatrics 167(2):156-161.
Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collings MW, Meehean WP 3rd. (2014).
“Effect of cognitive activity level on duration of post-concussion symptoms.” Pediatrics. 2014 Feb;133(2):e299-304.
Ciccia, Angela Hein, Meulenbroek, Peter, Turkstra, Lyn S. (2009). “Adolescent Brain and Cognitive Developments.
Implications for Clinical Assessment in Traumatic Brain Injury.” Topics in Language Disorders Vol. 29, No. 3: 249-265
Cicerone, K (2002) Remediation of working attention in mild traumatic brain injrry. Brain INjury
Cicerone, KD. et al. “Evidence Based Cognitive Rehabilitation: Updated review of the literature from 2003-2008".
Archives of physical medicine and Rehabilitation Journal, Vol 92 No. 519, 2011Z
Eisenberg, M. et al. (2013). “Time Interval Between Concussions and Symptom Duration”. Pediatrics (10) 1542
Haskins, Edmund C. “Cognitive Re, 16, 185-195habilitation Manual: Translating Evidence- Based Recommendations
into Practice.” ACRM Publishing, Virginia (2012).
LinguiSystems Testing Guide, 2011 Edition. LinguiSystems Inc. East Moline, Illinois
McCrory, P., Meeuwisse, W., Aubry, M., Cantu, R., et al. (2013). “Consensus Statement on Concussion in Sport, Zurich
International Conference 2012". British Journal of Sports Medicine 47:250-258
Roberts, Greg et al. (2008) Evidence-Based Strategies for Reading Instruction of Older Students with Learning
Disabilities. Learning Disabilities Research & Practice, 23(2), 63–69
Vermont Brain Injury Association: School Sports and Concussion Toolkit; revised 2013
www.cdc.gov/concussion