Disclaimer Best Prac-ces for Treatment of Concussion/mTBI

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1 Disclaimer Best Prac-ces for Treatment of Concussion/mTBI I have nothing to disclose other than the 9tle is a bit misleading McKay Moore Sohlberg University of Oregon Acknowledging the current state of the field here s what I hope to do this hour Provide a brief defini9on and orienta9on to the popula9on Bemoan the lack of evidence Encourage con9nued EBP and PBE and give some examples Share the clinical tenets and an overview of the pending Clinicians Guide for Treatment of mtbi being produced by a consensus panel of research and clinical experts serving veterans and service members What is a concussion (mtbi)? A recognized clinical syndrome of biomechanically induced altera9on of brain func9on, typically affec9ng memory and orienta9on, which may involve loss of consciousness Descriptors overlap with defini9on of mild trauma9c brain injury (mtbi) (McCrory et al., 2013) Four Defini-onal Construc-ons 1. Direct blow to head, face, neck or place that transmits impulsive force to head 2. Rapid onset of spontaneously resolving neurological impairment 3. Possible neuropathological changes with mainly func9onal (not structural) changes 4. May or may not involve loss of consciousness; usually shows sequen9al symptom resolu9on with some symptoms taking longer Severity and -me parameters Some specify that LOC must be less than 30 minutes PTA is absent or less than 24 hours GCS is greater than 13 All defini9ons agree that the mechanism is a biomechanical force sufficient to cause temporary altera9on in mental status and LOC is not required 1

2 Physiological changes Neurometabolic Cascade (Giza & Hovada, 2001) Neuroimaging and other neurophysiological findings have provided evidence of subtle brain changes associated with persistent post- concussion symptoms (De Beaumont et al., 2012; Fitzgerald & Crosson, 2011; Giza et al., 2001; Green, Koshimori, & Turner, 2010; Shenton et al., 2012) The Urgency to Understand this Clinical Syndrome Driven by Two Popula-ons Sports Concussion Sports- related concussion cases in US range million annually 5-15% experience ongoing symptoms at 90 days Post deployment Vets and SM Signature injury Numbers are substan9al The popula9on- based rate inclusive of all e9ologies (falls, MVA, sports) about 600 per 100,000 Es9mated 3.8 million mtbi annually That said The overwhelming majority of individuals experience a full recovery over the course of a few days to no more than a few months Individuals who present in the chronic phase represent an atypical paeern Prospec9ve studies find these individuals ofen have complica9ng factors: pain, nega9ve beliefs/expecta9ons, limited social support etc. Origin of Persistent Cogni-ve Symptoms: Not Clear Vast majority recover in 3 months Subset (5-15%) have ongoing cogni9ve and/ or soma9c complaints Differing opinions on why Related to psychological factors? Related to soma-c symptoms? Brain related changes? Likely mul-factorial What to do? The underlying causes of persistent symptoms for individuals unable to resume previous ac9vi9es are complex and not well understood and the literature on managing these symptoms is nascent. Lack of EBP Sports concussion literature focuses almost exclusively on return to play issues Recommenda-ons regarding cogni-ve and physical rest are now mixed 2

3 SCORE: Randomized Controlled Trial of Cognitive Rehabilitation for Service Members with Mild Traumatic Brain Injury Amy O. Bowles, MD Douglas B. Cooper, PhD, ABPP-CN Melissa R. Ray, SLP-CCC M. Marina LeBlanc, OTR Acknowledgements This work is supported in part by the following: Defense and Veterans Brain Injury Center (DVBIC) Telemedicine and Advanced Technology Research Center (TATRC) Department of Veterans Affairs, Veterans Health Administration: Office of Research and Development, Health Services Research and Development Service (VA HSR&D IIR ) Clinical Sciences Research and Development (VA CSRD W81XWH ). Rehabilitation Research and Development Career Development Award to Dr. Kean (CDA IK2RX000879) Slide 14 of 49 Research Design Prospective, randomized control treatment trial of cognitive rehabilitation for OEF/OIF Service Members with a history of mtbi and persistent (3 to 24 months post-injury) cognitive complaints Primary Outcome Measures Paced Auditory Serial Addition Test Symptom Checklist 90-Revised (SCL-90-R) Total Score Subscales (anxiety; depression; somatization) Key Behaviors Change Inventory (KBCI) Inattention; impulsivity; apathy; unawareness of problems interpersonal difficulties; communication problems; somatic difficulties; emotional adjustment Slide 16 of 49 Secondary Outcome Measures Symptom Complaints Functional Status Antecedents of change Neurocognitive abilities Strength of treatment alliance Four Treatment Arms Arm 1. Psychoeduca-onal control group Arm 2. Non- therapist directed computerized cogni-ve rehabilita-on Arm 3. Therapist- directed individualized cogni-ve rehabilita-on Arm 4. Integrated interdisciplinary cogni-ve rehabilita-on combined with cogni-ve behavioral psychotherapy Slide 17 of 49 3

4 Results No difference on the primary outcomes between the groups although the treatment groups ended up on the subclinical range The therapist directed and integrated cogni-ve rehabilita-on groups had superior outcomes on the Key Behaviors Change Inventory Conclusions Preliminary Support for Cognitive Rehabilitation Improvements beyond treatment as usual (augmentative) Subjective improvement of cognitive functioning, not objective neurocognitive test performance Interventions are not effective for all subjects Key Questions Applying a single intervention/group of interventions to a heterogeneous sample Is it realistic to expect a treatment response in majority of subjects? Prac-ce based evidence Retrospec9ve reviews Documen9ng and archiving your interven9on hdp://jslhr.pubs.asha.org/ Crooke, P. & Olswang, L. (in press) Prac9ce- based research: Another pathway for closing the research prac9ce gap. Journal of Speech Language Hearing Research. Sohlberg, M.M. & Kucheria, P. et al. (in press). Developing injury interven9ons on both ends of the con9nuum depends upon early research partnerships and feasibility trials. Journal of Speech Language Hearing Research. Prac-ce- based research acknowledges the value of understanding clinical decision- making in everyday contexts as an important complement to evidence generated in laboratories. A Retrospec-ve Review (Sohlberg & Ledbeder, in press) Goals Examine SLP role in concussion management Examine treatment op9ons and clinical ra9onale Report outcomes and iden9fy feasible treatments Method Coded demographics, treatments, goals, and outcomes for 24 of 63 cases referred over 36 months Selec9on criteria were symptoms persis9ng at least 2 months with adverse impact on school performance 4

5 Clinician s Guide to Cogni-ve Rehabilita-on in mtbi Development of a clinician manual to provide guidance on how to plan and implement individualized cognibve rehabilitabon intervenbons for cognibve challenges associated with mtbi in SM and Veterans. Expert clinicians and scholars represenbng mulbple disciplines collaborated at working meebng and electronically Douglas B. Cooper PhD, ABPP- CN Micaela Cornis- Pop PhD, CCC- SLP Leslie Freeman Davidson, PhD OTR/L Shari Goo- Yoshino, M.S., CCC- SLP Carol Smith Hammond, PhD, CCC- SLP Mary Kennedy, PhD, CCC- SLP, BC- ANCDS Don MacLennan, MA CCC- SLP R. Kevin Manning, PhD, CCC- SLP Pauline Mashima, PhD, CCC- SLP Collaborators Leslie Niea, MS CCC- SLP Linda M. Picon M.C.D., CCC- SLP Mary Vining Radomski, PhD., OTR/L Melissa Ray M.S., CCC- SLP Carole R. Roth PhD CCC- SLP, BC- ANCDS Maile Singson MS, CCC- SLP Lyn Turkstra PhD CCC- SLP, BC- ANCDS Rodney D. Vanderploeg, PhD., ABPP- CN Six Guiding Principles 1. Focus on Func9on Overarching goal is to help resume focus valued func-on and ac-vi-es. Assessment must include iden-fica-on of factors within the cogni-ve context of everyday ac-vi-es 2. Cul9vate Therapeu9c Alliance Transparency in the therapeu-c process facilitates a shif in ownership from clinician to client as they iden-fy goals, strategies, 3. Acknowledge Mul9factorial Complexi9es Medical and behavioral health comorbidi-es are well- established Guiding Principles Cont. 4. Facilitate Stakeholder Collabora9on Given complexity, need mul-disciplinary and natural supports involved 5. Recruit Resilience Be sensi-ve to core values as related to overcoming adversity 6. Promote Realis9c Expecta9ons for Recovery Posi-ve expecta-ons translate to self- efficacy and engagement Context of Cogni-ve Rehabilita-on Mo9va9onal interviewing Dynamic coaching 5

6 A"strong"SM/V-clinician"partnership"provides"the"founda9on"for"the"therapeu9c"process." Partnerships"are"built"upon"trust,"a"product"of"transparency"and"mutual"respect."Ini9ally"the" clinician"may"assume"greater"responsibility"for"guiding"the"therapeu9c"process;"however,"over" 9me"the"responsibility"shiCs"from"the"clinician"to"the"SM/V"as"they"collaborate"to"address" reported"difficul9es"and"implement"strategies"to"facilitate"success"in"everyday"ac9vi9es."the" goal"of"the"partnership"is"to"ul9mately"transfer"responsibility"for"goal"achievement"to"the"sm/ V"who"becomes"the"expert"at"solving"his/her"own"cogni9ve"difficul9es." Therapeu9c"Prompt/Ques9on"Example:" What"is"it"that"you'd"like"to"do? " What"can"we"do"to"help"you"get"you"where"you"want"to"go? " Therapeu9c"Management"Tips"and"Examples:" Employ"ac9ve"listening"techniques"(e.g.,"mo9va9onal"interviewing)"to"learn"the"SM/V's" core"values"and"what"s/he"would"like"to"achieve"through"par9cipa9on"in"therapy." Allow"the"SM/V's"goals"to"drive"the"therapeu9c"process." Resist"the"impulse"to"be"the"expert"within"the"partnership,"and"suppress"the"desire"to" engage"in"excessive"assessment"to"iden9fy"a"discrete"e9ology"of"the"reported"problems.% The"clinician's"primary"goal"is"to"help"the"SM/V"improve"daily"func9oning."! Interven-on Op-ons Personalized Educa9on and Understanding Cogni9ve Strategy Training Direct Training of Cogni9ve Impairments Selec9on and Training the Use of an Assis9ve Technology Device Environmental Management Personalized Educa-on Have a clear understanding of the PURPOSE of the educabon exercises Personalize the InformaBon Balance EducaBon of Strengths and Weaknesses Cogni-ve Strategy Training Strategy SelecBon and IntroducBon Need to be ThoughOul and SystemaBc Therapy Should Provide Appropriate PracBce for Using the Strategy EvaluaBon of Strategy Use Should Determine Type and Amount of PracBce Direct Training of Cogni-ve Processes Therapy Tasks Should be Organized According to a TheoreBcal Model Provide Sufficient RepeBBon and Pa9ent Performance Drives Clinical Regimen Combine Drills with Strategy Training IdenBfy and Measure FuncBonal Goals Training Assis-ve Technology for Cogni-on Device SelecBon and IntroducBon Need to be ThoughOul and SystemaBc Therapy Should Provide Appropriate PracBce for Using the Tool EvaluaBon of ATC Use Should Incorporate Device Knowledge, Use and Impact 6

7 Environmental Management Iden9fica9on Should be Collabora9ve and Based on Observa9on Natural Supports Need to be Iden9fied Use and Impact Need to be Evaluated Summary It is unlikely we will iden9fy a management approach that will work for the diverse popula9on of individuals with ongoing cogni9ve symptoms postconcussion We have a number of established therapeu9c frameworks with cross- popula9on evidence We need to build our PBE using interven9ons shown to have poten9al for this popula9on 7