Cognitive Rehabilitation & OT

‘Making the Most’ of the

Concussed Brain

Janet Parkinson, OTR/LJefferson Comprehensive Concussion Center

Thomas Jefferson University Hospital Department of Rehabilitation Medicine

• Background: Concussion is a mild TBI that sets off a complex chain of events including anatomical, metabolic, and physiological changes in the brain and body. • diffuse axonal injury nerve cell transmission failure

• metabolic changes period of hyperglycemia

• followed by prolonged metabolic depression

• increased heart rate

• autonomic dysregulation

• Diffuse axonal injuries are not seen by MRI/CT Scan; must rely on patient report and Neuropsychological testing to diagnose

Background & Evidence

The Neurometabolic Cascade of Concussion

http://www.youtube.com/watch?feature=player_embedded&v=KrvC2UUEJ8Yhttp://www.youtube.com/watch?v=uEGXcNNyzpY&feature=player_detailpagehttp://www.youtube.com/watch?v=lzkawCHfUB0

Background & Evidence

Rest Vs. Activity

• Given that both mental and physical exertion can change the metabolic activity of the brain, cognitive and physical activities could potentially worsen the metabolic mismatch after concussion. Therefore cognitive and physical rehabilitation interventions and other activities (eg, schoolwork/athletic engagement) may need to be tailored so that they are not detrimental to recovery. (Majersky et al, 2008)

• However, prolonged rest can lead to undesirable results such as: physical deconditioning, metabolic disturbances, fatigue, and depression. (Leddy et al, 2012)

• What is most beneficial?

• What is the evidence?

Evidence

• 2007

• Greisbach, et al• BDNF levels have been

shown to significantly

increase with exercise in

animal studies with mild

brain injuries when

exercised from PID 14-20;

however BDNF up-

regulation was not

significantly found with

exercise acutely (0-6 days)

or very delayed (30-36

days) after mild injury.

• 2008

• Majerski, et al• Students who reported

moderate levels of

cognitive and physical

exertion (eg, participation

in school and light activity

at home such as jogging)

over the first month after

injury appeared to have

better neuropsychological

outcomes than those with

very little or very high

levels of activity.

• Similar to (Brown et al,

2015) findings related to

solely cognitive activity,

highest levels had longest

symptoms resolution. But

total rest not necessary.

• 2010

• Leddy, et al • Patients with PCS (not

improving for months prior)

performing ‘Sub-symptom

Threshold Exercise Training’

(SSTET) significantly

improved symptomatically

and were able to achieve

maximum exertion without

symptom exacerbation and

return to sport/work .

Evidence

• 2015

• Thomas, et al

• Adolescent patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to 2 groups : (1)strict rest for 5 days; (2)1-2 days rest, followed by stepwise return to activity.

• No clinically significant difference in neurocognitive or balance outcomes. However, the “strict rest” group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P < .03) and slower symptom resolution.

Conclusion:

• TIMING AND MODERATION ARE KEY!!!!

• How to tailor / moderate??

Stepwise return to activity based on SYMPTOMS!

(current concussion specialists agree with allowing 2 point

increase in symptoms before discontinuing

cognitive/physical activity)

Experience has shown that most adults are fully recovered by 3 weeks post concussion and children by 1 month if they follow these guidelines…

BUT…

What happens when symptoms do not go away in this time frame?

◦ Medications / Supplements **see appendix A

◦ Occupational / Cognitive Therapy

◦ Physical / Vestibular Therapy

◦ Vision Therapy

◦ Speech Therapy

◦ Psychotherapy

Experience

An Occupational Therapist will evaluate and focus treatment to address deficits in cognitive skills via remediation exercises & compensatory strategies to improve performance with skills such as

- memory - concentration/ attention

- problem solving - organizational skills

- comprehension

It is a structured program, in a controlled environment, that will gradually increase cognitive demand on the patient, and facilitate recovery and return to prior life roles.

Occupational [Cognitive] Therapy

Plan of Care:

Cognitive remediation

Compensatory technique

training

Functional ADL/IADL training

Work and school reintegration

& accommodations

Coordination and response

time training

Oculomotor skills

“Return to Learn” protocol

Goals:

Improved cognitive functioning

to enable optimal /

independent functioning with: ADLs & home management

Work related tasks

School responsibilities

Leisure activities

Community living skills

Occupational Therapy

Attention & Memory Training

◦ Remediation:◦ Attention exercises & programs to develop

sustained, selective, alternating, and divided

attention skills. (Haskins et al, 2013)

OT Specific Treatment

RemediationAttention Training & Hierarchy

APT (Attention Process Training) • A structured program of attention training consisting of 5 different tracks

corresponding to a hierarchically-organized, clinical theory of attention.

• This theory states that there are 5 major types of attention: • Focused

• Sustained

• Selective

• Alternating

• Divided

• This approach to the treatment of attention deficits has been empirically validated in a study by Sohlberg et al. (2000), in which the authors compared the efficacy of APT with that of brain-injury education. They found APT to enhance performance on a number of functional tasks and neuropsychological measures of executive attention and working memory. Subjects also self reported improved attention abilities. (Haskins et al, 2013)

RemediationWorking Attention and Working Memory

N-Back Exercises:(Ciserone, 2001) (Jaeggi et al, 2008- Also linked to improving fluid intelligence)

• The general N-back procedure consists of the presentation of a sequence of stimuli with the requirements for the participant to continuously report the stimulus occurring “n” number of stimuli previously.

• Various modalities and protocols (auditory, visual, pictural, numeric, dual-n-back)

• (*video*)

• Neuropsych tests improved by N-Back • 2&7 selective attention test

• Continuous Performance Test of Attention (CPTA)

• Paced Auditory Serial Addition Test (PASAT)

• In 3 out of 4 trials the experimental group had significantly meaningful improvement from pretesting, but the control group did not significantly improve. (Cicerone, 2001)

External Techniques Internal Techniques

Electronic Reminders

Recorders

Planners/ Calendars

Environmental Cues

School and Work-place

Accommodations (written

notes/ word banks)

Assistive Technology

(medication watches/

stove-burner alert)

Rehearsal

Visualization

Association Techniques

• Pairing

• Chaining

• Mnemonics , i.e. Acronyms

Chunking (digits; words; phrases)

OT Specific TreatmentMemory Compensatory Techniques

OT Specific TreatmentOculomotor Skills

• Tracking• Fixation

• Maintaining focus on a target without distraction

Increase difficulty with busy background/ adding peripheral awareness

• Smooth Pursuits **important for the athlete

• Following target

• Eye tracing/ mazes

• Saccades • Eye “jumps”

• varying distances

• Words/ numbers/ letters across a page

• Columns

• Environmental targets

• Vergence (typically convergence)

• Brock String• 3 beads on a string – moving focus

in and out.

• Pencil push-up technique • Focusing on point of pencil –

pulling in to point before it doubles, hold gaze, then switch out and back.

• Accommodation• Near-far gaze changes

• 2 matching charts – one near/ one far. Read the charts alternating one character near and one character far.

• Can improve ability to quickly clear words when gaze changing as well as improve endurance.

Oculomotor Exercises (preparatory)

OT Specific TreatmentOculomotor Skills

• Therapeutic Activities

• Activities designed to address oculomotor impairments:

• Fixation = beading; items into a tube

• Pursuits = following swinging ball, route finding, following flashlight/laser

• Saccades = environmental scanning, chart comparison, connect the dots/ letters, reading/scanning passages, “whack a mole”, plotting points, flashlight/laser tag

• Accommodation = near/far design copy, copying from board/ tabletop computer, data entry

• Convergence = ball toss/ zoom pass, marbles

Reading Comprehension

• Combining attention, memory, and visual skills to read and identify main point and important details in short story, paragraph, and correspondence

• Training on study strategies to improve retention / insight into new learning.

• Read and interpret passages, graphs, charts, & labels and attend to details in order to accurately complete questions or a task designed to evaluate comprehension of the material (i.e. medication management, correctly reading labels and setting up pill box)

OT Specific Treatment

School and Work Re-integration

◦ Individually designed work and school related tasks, with gradual increase to the level of difficulty

◦ Simulation of the work and school environment, including the stressors and/or distractions that may be present

◦ Examples: Copying notes/ study techniques & quizzes

Creating / Interpreting charts/ spreadsheets

Prioritizing and scheduling

Organizing / filing paperwork

RN functional math & problem solving

Money management / making change

Multitasking : visual attention with oral comprehension, cognitive circuit requiring alternating attention, working attention with exertional task

OT Specific Treatment

Stage Activity Objective

No Activity Complete cognitive rest– no school, no homework, no reading, no texting, no video games, no computer work.

Rest/Recover

Gradual reintroduction of cognitive activity

Relax previous restrictions on activities and add back for short periods of time 5-15 min.

Gradual controlled increase in sub-symptom threshold cognitive activities

Homework at home before schoolwork at school

Homework in longer increments (20-30 minutes at a time).

Increase cognitive stamina by repetition of short periods of self-paced cognitive activity.

School re-entry Part day of school after tolerating 1-2 cumulative hours of homework at home.

Re-entry into school with accommodations (breaks prn in quietplace, preprinted class notes, additional time for assignments, excuse non-essential work, tutoring as needed, no testing until full day, focus on in-school work & rest at home

Gradual reintegration into school Increase to full day of school. Tests can be introduced (only 1 per day & untimed).

Accommodations decrease as stamina improves

Resumption of full cognitive load Accommodations are removed, construct a plan for completing missed academic work.

Full return to school; may commence Return-to-Play protocol

Return to Learn Protocol (Master et al, 2012)

OT Specific TreatmentGrading Cognitive Tasks

• Adding more cognitive demand:

• Processing (alternating attention to rule, conditions… “if this,

then that”)

• Problem solving (deductive reasoning, functional, verbal-

situational, concrete abstract)

• Switching/Prioritizing Tasks & Multitasking

• Environmental Press

• Time pressure

• Environmental distractions

• Exertional Demand

DATE

TIME

LOCATION School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

School: _______

Home:________

Work: ________

DURATION

ACTIVITY/

STRESSOR

SYMPTOM (pre/post)

HEADACHE

FATIGUE

CONCENTRATION

IRRITABILITY

DIZZINESS

BLURRY/ DOUBLE VISION

LIGHT SENSITIVITY

NOISE SENSITIVITY

OTHER:_____________

OTHER:_____________

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Cognitive / Activity Monitoring Log

Symptom Monitoring

OT Specific Treatment

Relaxation and Cognition

• A growing body of research suggests that meditation can enhance various cognitive functions, including attention, memory, and executive functions (Gard et al, 2014).

• The results of several studies revealed significant improvements in overall cognitive function & especially attention via

• yoga-meditation

• self-relaxation

• transcendental meditation (which focuses on mindfulness)

• mindfulness meditation, MBSR (mindfulness based stress reduction), & mindfulness based cognitive therapy

• What is mindfulness???

• Why is it such a hot topic???

Mindfulness

• Quoting the website “mindfulnessandmore.com” mindfulness is:

• About paying attention and living your life in the richness of the present

moment.

• It’s a simple practice that strengthens the mind’s ability to stay focused on

what is happening right now and to be open to experience.

• Why is it beneficial to our patients?

• Scientific research findings on MBSR and other mindfulness-based programs

over the past 30 years have shown many benefits to participants.

• Reduced anxiety & depression Improved concentration

• Reduced chronic pain Improved sleep quality

• Decreased fatigue Increased compassion for self/others

• Improved emotional regulation Decreased interpersonal problems

• Practice…

• Speech & Language Therapy – Speech therapy can address cognitive remediation with a focus on comprehension & expression of language. When these symptoms are primary, we recommend Speech Therapy instead of Occupational Therapy. When memory, attention, vision, & coordination take precedence, OT would be preferred. At times both services may be warranted.

• Vestibular/ Physical Therapy – Physical therapy can address neck and headache pain, as well as aerobic and sport related activity tolerance. Also Physical Therapists specializing in vestibular rehab will address dizziness and imbalance that frequently accompany concussion.

• Vision Therapy – Vision therapy can be very effective in cases where visual symptoms persist even after the vestibular system has cleared. Patients are evaluated by a developmental optometrist (COVD.org) and can be prescribed a series of eye exercises as well as prescription lenses to improve a variety of visual problems (convergence, photophobia, etc.) *May refer to OT for in-office vision therapy.

• Psychology & Psychiatry - Psychological symptoms such as depressed mood, irritability, and anxiety are often associated with post-concussion syndrome. These symptoms can in-turn limit recovery. Counseling and medication management help patients adapt and complete their recovery.

• Biofeedback / Alternative Medicine – Biofeedback and relaxation training can enhance the effects of medication and gives patients the tools necessary to gain greater control over their pain, anxiety, etc.

Additional Therapies

The literature shows that cognitive rehabilitation interventions have resulted in improved performance on selected neuropsychological testing. (Leddy et al, 2012)

Rehabilitation of attention processes have received the most empirical support [Attention Process Training (APT) & N-back](Rohling et al, 2009) (Ciserone, 2001) (Leddy et al, 2012)

Findings highlight gaps in the scientific evidence supporting cognitive rehabilitation, suggesting the need for further research efforts (Rohling et al, 2009)

Implications for the Future

• Currently: Research studies approved/ starting to consent

patients

• Rehabilitation department currently assisting with data

collection on all concussion patients to provide further

evidence, and help guide rehabilitation after concussion in the

future.

Current Efforts @ Jefferson

Comprehensive Concussion Center

1. Cicerone K. Remediation of ‘working attention’ in mild traumatic brain injury. Brain Injury. 2002; 16(3): 185-195.

2. Gard T, Holzel BK, Lazar SW. The potential effects of meditation on age-related cognitive decline: a systematic review. 2014

3. Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulationand recovery of function. Neuroscience. 2004; 125(1): 129-39.

4. Griesbach GS, Gomez-Pinilla F, Hovda D. Time Window for Voluntary Exercise-Induced Increases in Hippocampal Neuroplasticity Molecules after Traumatic Brain Injury is Severity Dependent. Journal of Neurotrauma. 2007; 24(7): 1161-1171.

5. Haskins E, Cicerone K, Dams-O’Connor K, Eberle R, Langenbahn D, Shapiro-Rosenbaum A. Cognitive Rehabilitation Manual. American Congress of Rehabilitation Medicine. First Edition 2013: 76-79.

6. Jeggi S, Buschkuehl M, Jonides J, Perrig W. Improving fluid intelligence with training on working memory. Proc Nstl Acad Sci U S A. 2008 May 13; 105(19): 6829-33.

7. Leddy J, Kozlowski K, Donnelly J, Pendergast D, Epstein L, Willer B. A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post-Concussion Syndrome. Clinical Journal of Sports Medicine. 2010; 20(1): 21-27.

8. Leddy J, Sandhu H, Sodhi V, Baker J, Willer B. Rehabilitation of Concussion and Post-concussion Syndrome. Sports Health. Mar 2012; 4(2): 147-154.

9. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: Postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008; 43(3): 265-274.

10. Master C, Gioia G, Leddy J, Grady M. Importance of ‘Return-to-Learn’ in Pediatric and Adolescent Concussion. Pediatric Annals. Sept 2012; 41(9): 1-6.

11. Palmese CA, Raskin SA. The rehabilitation of attention in individuals with mild traumatic brain injury, using the ATP-II programme. Brain Injury. 2000 Jun; 14(6): 535-548.

12. Reibel, D. Ph.D. (2014). What is Mindfulness? Retrieved from http://www.mindfulnessandmore.com.

13. Rohling ML, Faust ME, Beverly B, Demakis G. Effectiveness of cognitive rehabilitation following acquired brain injury: a meta-analytic re-examination of Cicerone et al.’s (2000,2005) systematic reviews. Neuropsychology. 2009 Jan; 23(1): 20-39.

14. Sohlberg M, Mclaughlin K, Pavese A, Heidrich A, Posner M. Evaluation of attention process training and brain injury education in persons with acquired brain injury. Jclin Exp Neuropsychol. 2000 Oct; 22(5): 656-76

Citations

Appendix A

Common Concussion Medications

- Migraine/headaches:

Topomax- migraine prevention

Preventa migraine- migraines

Verapamil – bp and headaches

Lyrica- headaches

Cymbalta- anxiety ; depression; headaches

- Amitriptyline - for insomnia

- Amantadine – attention/cognition

- Aricept- memory

Common Concussion Supplements

- Vitamin B2 (Riboflavin) – anti inflammatory

- Magnesium – anti inflammatory

- Fish Oil – for neuronal sheath

- CoQ10 – anti inflammatory

- Melatonin – for sleep

- Butterburr – migraine/ sleep

- Vitamin B12 (if deficient)- memory loss, sleep

disorders (overly sleepy)

Tylenol and Non-steroidal anti-inflammatories are not recommended for post concussive headache as they can lead to rebound headaches