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Recovering from a Concussion: Strategies for Treating the Whole Person. David Everson, PT Erin Ingvalson, CCC/SLP Candice Gangl OTD, OTR/L Nicole LaBerge PT, ATP. Objectives:. Define a mTBI Understand the benefit of a multidisciplinary approach to treatment of a mTBI

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recovering from a concussion strategies for treating the whole person

Recovering from a Concussion: Strategies for Treating the Whole Person

David Everson, PT

Erin Ingvalson, CCC/SLP

Candice Gangl OTD, OTR/L

Nicole LaBerge PT, ATP

  • Define a mTBI
  • Understand the benefit of a multidisciplinary approach to treatment of a mTBI
  • Identify differences between the role and treatment goals of Speech, Physical and Occupational Therapy for patients with a mTBI
  • Define the differences between vision and vestibular treatment for a patient with mTBI
  • Identify treatment strategies and additional team support for the patient with persistent symptomology
traumatic brain injury
Traumatic Brain Injury

“Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head.”

traumatic brain injury1
Traumatic Brain Injury
  • Results in a graded set of clinical syndromes that may or may not involve loss of consciousness.
    • Fewer than 10% have a LOC
  • Resolution of the clinical and cognitive symptoms typically follows a sequential course
  • Typically associated with grossly normal neuroimaging studies
  • Acute clinical symptoms reflect a functional disturbance rather than structural injury
acceleration deceleration

Brain moves forward in skull

Frontal lobes strike inside of skull

Rebound contre coup injury to the occipital lobe

rotational injury
Rotational Injury
  • Brain rotates on axis causing stretching/tearing of axon
  • Stretching and tearing of blood vessels results in hematoma
  • Brain strikes skull causing contusion
neurometabolic cascade of concussion
Neurometabolic Cascade of Concussion
  • Cells activate pumps
    • Potassium ions out
    • Calcium ions into the cells
  • To move the ions back, brain increases metabolism
  • Calcium impairs the cells
    • Can’t make the energy to drive the ion pumps







% of normal















Cerebral Blood Flow





Neurometabolic Cascade Following Concussion/MTBI

(Giza & Hovda, 2001)

UCLA Brain Injury Research Center

causes of tbi all age groups
Causes of TBI –all age groups Accessed May 30, 2013

contact activities
Contact Activities

Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

wheeled activities
Wheeled Activities

Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

limited contact activities
Limited Contact Activities

Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

non contact activities
Non-Contact Activities

Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤19 Years — United States, 2001–2009 Morbidity and Mortality Weekly Report Weekly / Vol. 60 / No. 39 October 7, 2011

most common symptoms reported by high school athletes
Most Common Symptoms Reported by High School Athletes

Kontos, Elbin, French Collins, Data Under Review; N = 1,438

risk factors for protracted recovery 3 weeks

Learning Disabilities

  • History of migraines and migraine symptoms
  • Report of dizziness at injury
  • Age - the younger the longer the recovery
  • Gender
  • Repetitive concussions
Risk factors for protracted recovery (>3 weeks)
risk factors for protracted recovery 3 weeks1
Risk factors for protracted recovery (>3 weeks)
  • Brief LOC (<30 sec) not predictive of sub-acute or protracted outcomes following sports-concussion

---(Collins et al 2003)

  • Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery

---(Collins et al 2003)

  • On-Field dizziness best predictor of protracted recovery
  • Gender may influence concussions
    • (Colvin AC et all, The role of concussion history and gender in recovery from soccer-related concussion. Am J Sports Med. 2009;37(9):1699–1704)
pediatric athletes 18
Pediatric Athletes (<18)

American Academy of Pediatrics (AAP) recommends “conservative” management:

  • NO return to play on same day
  • Seriously, NO return to play on same day
  • When in Doubt, Sit them OUT!
individual recovery from sports mtbi how long does it take






Individual Recovery From SportsMTBI: How Long Does it Take?





N=134 High School Male Football Athletes



Collins et al., 2006, Neurosurgery

minnesota law
Minnesota Law
  • Minnesota Statute 121A.37
  • Effective September 1, 2011 Minnesota State Law requires coaches and/or officials to remove youth athletes from participating in any youth athletic activity when the youth athlete exhibits signs, symptoms, or behaviors consistent with a concussion; or is suspected of sustaining a concussion. When a youth athlete is removed because of a concussion, the youth athlete may not again participate in the activity until the youth athlete: no longer exhibits signs, symptoms, or behaviors consistent with a concussion; and is evaluated by a provider trained and experienced in evaluating and managing concussions and the provider gives the youth athlete written permission to again participate in the activity.
what are the risks of returning to activity before an injury is healed
What are the risks of returning to activity before an injury is healed?

Symptoms may last longer and become more intense.

New symptoms may occur.

Risk of repeat injury and risk of Second Impact Syndrome.

who might you see in the recovery process
Who might you see in the recovery process?

At Gillette we work as an interdisciplinary team with experts in a variety of fields to provide the best patient care and safe recovery.

Team Members Include:




Nurse Practitioners


Occupational Therapy

Physical Medicine and Rehabilitation

Physical Therapy




Social Work

Sleep Medicine

Speech Therapy

speech therapy

Speech Therapy

Erin Ingvalson, MS CCC/SLP CBIS

cognitive rest
Cognitive Rest
  • What is it?
  • Is it important?
  • How do you manage it?
what is cognitive rest
What is Cognitive Rest?
  • Avoidance and/or elimination of cognitive activity that causes or exacerbates post concussive symptoms
  • Best thought of as a continuum (McLeod & Gioia, 2010
is cognitive rest important
Is Cognitive Rest Important?
  • Research clearly documents metabolic crisis in the brain that occurs following concussion that results in reduced energy for physical and cognitive activity
  • Research on benefits of cognitive rest is divided and unclear
how do you manage cognitive rest
How Do You Manage Cognitive Rest?
  • Subsystem Cognitive Threshold Activity (Master, Gioia, Leddy & Grady 2012)

- goal is to keep cognitive activity below the level of triggering symptoms

- Child should stop cognitive activity at the point of developing the sensation of a dull pressure and prior to developing a headache

how do you manage cognitive rest1
How Do You Manage Cognitive Rest?

- After a period of cognitive rest the activity can be tried again at a lesser amount of time than the previous trial

- Work up to increase endurance for cognitive activity for longer periods of time with no break and no symptoms

how do you manage cognitive rest2
How Do You Manage Cognitive Rest?
  • Cognitive Activity Monitoring Log (CAM)

Gerard A. Gioia GA, PhD

return to learning
Return to Learning
  • Ultimate goal is to get the child back to school and normal routine as soon as possible following injury
  • If cognitive problems persist:

- provide school accommodations as necessary

- pursue additional evaluations as necessary

- continue to provide education and support

who evaluates for cognitive deficits in patients with tbi



Occupational Therapy

Speech Therapy

**A team approach is most effective

Who evaluates for cognitive deficits in patients with TBI?

Main Players

Supporting Players


Physical Therapy

Therapeutic Recreation

Social Work

what does the slp do
What does the SLP do?
  • Provide evaluation, treatment and education regarding speech, language, and cognitive communication disorders associated with TBI
  • Cognitive communication disorders

- Difficulty with language/communication as a result of impairments in general cognitive processes of attention, memory, and other executive functions

why a referral to speech language pathology

Word finding difficulties

Difficulties with focus and attention

Difficulties with short term and working memory

Decreased processing speed

Difficulties with planning and organization

Why a referral to Speech-Language Pathology?

Cognitive Communication Deficit

Functional Deficit

Difficulties talking with family, peers, teachers

Difficulties with written language

Difficulties following directions and reading

Decrease in grades

Social isolation

assessment of cognitive communication disorders
Assessment of Cognitive Communication Disorders
  • Assessment should be flexible and guided by patient factors, history, and chief complaints.
  • Assessment should include a combination of standardized and informal measures
standardized assessments
Standardized Assessments
  • Woodcock-Johnson Tests of Cognitive Abilities
  • Oral and Written Language Scales
  • Clinical Evaluation of Language Fundamentals
  • Rivermead

**Kids can often do well on standardized tests yet still demonstrate significant functional deficits

informal assessments
Informal Assessments
  • Behavioral considerations
  • Spontaneous discourse
  • Patient and family complaints
treatment of cognitive disorders
Treatment of Cognitive Disorders
  • Education
  • Individualized
  • Context based
  • Strategy training
  • Partner training
occupational therapy
Occupational Therapy

What does OT do after a brain injury?

  • Assist with handling changes to your day-to-day life.
  • Provide ideas to strengthen skills and make changes to your environment.
  • Our goal is to help you return to school, work, and daily activities.
occupational therapy1
Occupational Therapy

Examples of why to refer to OT:

  • Headaches while reading
  • Difficulties copying from the board
  • Unable to organize and complete multi-step projects
  • Sensitive to light, loud noises, and sensitive to getting hair washed
  • Forgetting to turn in/complete assignments
  • Continues to forget to take meds
  • Unable to read a recipe and bake (a previously loved task)
  • Easily distracted
occupational therapy evaluation after concussion
Occupational Therapy Evaluation after Concussion
  • Pt. and Family symptom interview
  • Functional vision screen
    • If time: Standardized visual perceptual test:
  • Functional cognitive assessment:
    • Memory, attention, executive function skills
  • **This is not all-inclusive, testing determined on a case to case basis
  • Includes the eye, optic nerve, and many parts of the brain
  • Process the sensory information in a persons environment and with the brain decides what to do with that information
  • Vision can be affected by injury and or disease to any of these components
treatment vision remediation
  • All treatment Is graded:
    • Static to dynamic
    • Body position changes
    • Environmental challenges
  • Tracking: following mazes, flashlight, watching the ball during practice
  • Saccades: HAART chart, X-sticks, naming items, copying from the board
  • Convergence: Pencil push-ups, cup toss, zoom-ball
treatment vision compensation
Treatment-VISION Compensation
  • Light sensitivity: Sunglasses, tinted lenses, transition lenses.
  • Reading: colored overlays, visual highlighters, white on black, increased font, prism glasses
  • Note taking: slant board, location of desk, audio recording pens
  • Technology Use: Dark background, visual overlays, larger font, decreased brightness
cognition cognition cognition
Cognition, Cognition, Cognition
  • Cognitive deficits after a concussion may last longer than the concussion symptoms.
  • Important to access school records
  • Research on patients with a concussion has found that Cognitive Symptoms typically resolve within a 3-6 month time frame. *
  • Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of post-concussion syndrome following mild head injury. Clinical and Experimental Neuropsychology. 2001; 23 829-836
  • Borg J, Holm L, Peloso PM, Cassidy JD, Carroll LJ, von Holst H, Paniak C, Yates D. Non-surgical intervention and cost for mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine. 2004; 43: 76-83
executive function skills and ot
Executive Function Skills and OT
  • Executive Function domains include:
    • Initiation and Inhibition
    • Cognitive Flexibility/Shifting set
    • Working Memory
    • Planning and Organization
    • Self-regulation/Monitoring
  • Executive Dysfunction symptoms a family might note could include:
  • Lazy, doesn’t do anything
  • Saying things that are inappropriate
  • Repeating the same things over and over
ot return to function at gillette
OT Return to Function at Gillette
  • We have developed a Four-stage Return to Function protocol at Gillette.
  • Each stage has:

1. a different set of cognitive screeners or standardized tests

2. an overview/ goal for the stage,

3. Targeted skills the patient should demonstrate by the end of the stage

4. parent take-aways

return to school when and how
Return to School: When and How
  • When
    • BEFORE returning to sports
    • Individualized
  • How
    • 504 plan/accommodations
    • Extended time for quizzes/tests,
    • Breaks throughout the day
    • Preferential seating
treatment sensory sensitivity
  • Skill Building:
    • Graded introduction of stimuli, activity completion in multiple environments with various sensory input levels
  • Compensation:
    • Sunglasses, tinted glasses, earplugs, noise canceling head phones, school accommodations, safe and comfortable space at home
treatment daily activities
  • All treatment strategies based on functional daily activity needs.
  • Completing the difficult activities in graded environments with use of compensation as needed

-Cooking example

occupational therapy2
Occupational Therapy

Discharge Goal:

  • Pt. is able to complete tasks independently due to skill acquisition or with use of compensatory strategies as needed to independently and successfully get through their day.
  • Our goal is to graduate from therapy and be able to use what was learned to be successful each day!
physical therapy

Physical Therapy

Nicole LaBerge, PT ATP

physical therapy1
Physical Therapy

What does PT do after a brain injury?

GOAL: Assist with returning the patient to their previously tolerated physical activities, including Sports

  • Assess and Treat Balance, Vestibular Function, and complete the Return to Activity Protocol
  • Monitor patient symptoms during sessions
physical therapy2
Physical Therapy
  • Common Symptoms after a mTBI:
    • Dizziness
    • Headaches
    • Motion sickness
    • Nausea
    • Blurry Vision
    • Sensitivity to Light
    • Sensitivity to Sound
    • Deconditioned/Decreased Activity Tolerance
    • Musculoskeletal Pain (neck, back)
physical rest but not forever
Physical Rest… but not forever!

Physical Rest: Both feet on the ground

  • No physical activity
  • No sports
  • No exercise/working out
  • No strenuous activity
  • No recess
  • No gym class
physical rest but not forever1
Physical Rest… but not forever!
  • Physical Rest
  • Rest from Sports
  • The body maintains balancefrom three systems:
    • Vision
    • Proprioception (touch sensors in the feet, trunk, and spine)
    • Vestibular system (inner ear)
  • Sensory input from these systems is integrated and processed by the brainstem.
  • In response, feedback messages are sent to the eyes to help maintain steady vision and to the muscles to help maintain posture and balance.
vestibular system
Vestibular System
  • Includes parts of the inner ear and brain
  • Process the sensory information involved with controlling balance and eye movements.
  • If injury or disease damages these processing areas, vestibular disorders can result.
common vestibular related symptoms after concussion
Common Vestibular-Related Symptoms after Concussion
  • Dizziness
  • Loss of Balance
  • Nausea
  • Difficulty changing positions (head and body)
  • Car sick
  • Headache
vestibular functional limitations
Vestibular Functional Limitations
  • Walking – hallways, stairs
  • Sports and Recreational Activities
  • Turning Head – looking in different directions
  • Sit to/from standing
  • Rolling over in bed
  • Lifting
  • Getting in/out of car
physical therapy evaluation
Physical Therapy Evaluation
  • Subjective report of symptoms
  • Vestibular and Oculomotor Assessment
  • Static and Dynamic Balance Tests
  • Cervical ROM and strength
  • Scapular ROM and strength
  • Resting Vitals
physical therapy treatment
Physical Therapy Treatment
  • All treatment is graded
    • From static to dynamic
    • Body position changes
    • Environmental challenges
  • Vestibular and Oculomotor Exercises
  • Balance exercises
  • BPPV assessment and treatment
  • Manual Therapy techniques
  • Transition to Return to Activity (RTA)
physical therapy3
Physical Therapy
  • Return to Activity Protocol

Provide education to patients/families on how to find target heart rate for each stage:

    • Karvonen Heart Rate Formula

Stages for Return To Activity

    • No activity and rest until asymptomatic or instructed by Provider
    • Stage 1: Light aerobic exercise (30-40% HR)
    • Stage 2: Sport-specific training (40-60% HR)
    • Stage 3: Non-contact drills (60-80% HR)
    • Stage 4: Full practice drills except contact (80-90% HR)
    • Patient will take final ImPACT test and if cleared by Provider, can then return to full contact activities.
    • Recommend THREE full practices before return to Sport
contact information
Contact Information
  • Erin E Ingvalson MS, CCC/SLP CBIS
    • Speech Language Pathologist
    • Gillette Children’s Specialty Healthcare
    • St. Paul, MN
    • [email protected]
  • Candice Gangl, OTD, OTR/L
    • Occupational Therapist
    • Gillette Lifetime Specialty Healthcare St. Paul, MN (M-W)
    • Gillette Children\'s Specialty Healthcare Maple Grove, MN (Th-F)
    • [email protected]
  • David Everson, PT
    • Rehabilitation Supervisor --Minnetonka Clinic
    • Gillette Children’s Specialty Healthcare
    • Neuro Trauma Lead for Rehab Therapies
    • [email protected]
  • Nicole B. LaBerge, PT, ATP

Special Thank You to


Gillette Children’s Specialty Healthcare

---She completed some of the graphs in this presentation

vision definitions
Vision Definitions
  • Visual Perception: the ability to derive meaning from visual information
  • Visual Memory: The ability to store visual information and recall for later use
  • Visual Attention: the ability to focus on specific elements and use that information to complete tasks.
vision definitions1
Vision Definitions
  • Visual Acuity: The clarity in which one’s eye sees (20/20)
  • Visual Tracking: The ability for a person to focus and follow objects in their environment.
  • Saccades: The quick eye movements used for scanning, tracking movements, and reading
  • Convergence: The ability of a person to bring eyes together to focus in on close work.
vestibular definitions
Vestibular Definitions
  • Dizziness is a sensation of lightheadedness, faintness, or unsteadiness.
  • Vertigo has a rotational, spinning component, and is the perception of movement, either of the self or surrounding objects.
  • Disequilibrium simply means unsteadiness, imbalance, or loss of equilibrium that is often accompanied by spatial disorientation.