RECONNECTING AFTER CONCUSSION: ADDRESSING PCS WITH IM

Heather Barr MS CCC-SLP

LEARNING OBJECTIVES

Ø Identify key symptoms of post-concussive syndrome (PCS)

Ø Identify application for use of IM in this patient population

Ø Learn new treatment activities to incorporate into successful therapy sessions

CONCUSSION

Ø  A concussion is a type of traumatic brain injury that is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull.

Ø  It creates a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:

w  Period of loss of consciousness (brief or extended) w  Any loss of memory for events immediately before or after the

accident w  Any alteration in mental state w  Any period after the injury in which one is unable to form new

memories

IMAGING TO ASSESS THE BRAIN

Ø If an MRI/CT scan is normal and there was no loss of consciousness you should NOT assume there is no disruption to the brain. Neuro-imaging techniques are insensitive to the metabolic effects of concussion.

Ø Neuro-imaging rules out more severe injury, but does not confirm or deny the presence of concussion.

CONCUSSION (cont.)

Mechanism of Concussion

Ø  May or may not persist, for varying lengths of time Ø  May exhibit persistent emotional, cognitive, behavioral and physical

symptoms alone or in combination, which may produce a functional impairment.

Ø  Some may not become aware of, or admit, the extent of their symptoms, until they attempt to return to normal functioning.

Ø  Symptoms may also be overlooked in the face of more dramatic physical injury (e.g. orthopedic or spinal cord injury).

Signs & Symptoms

PERSISTANT SYMPTOMS

Ø  80 % improve within 3 weeks; however, some of the following symptoms may linger.

COGNITIVE COMPONENTS PHYSICAL COMPONENTS EMOTIONAL/MOOD COMPONENTS

q Difficulty thinking clearly q Need more time to think q Difficulty with attention/

concentration q Difficulty remembering q Difficulty doing two things

at once

q  Headache q Nausea/ vomiting q  Balance problems/

Dizziness q  Fuzzy/blurry vision q  Fatigue q  Sensitivity to noise or

light q  Feeling foggy or groggy

q  Irritability q  Impatience q  Sadness q  Reduced tolerance for

stress q Nervousness/ anxiety q  Lack of initiative, apathy q  Sleep more/less than

usual

POST-CONCUSSIVE SYNDROME

Ø  Post-Concussive Syndrome (PCS) – term to describe a constellation of symptoms that persist after the injury. w  If symptoms persist more than 4-6 weeks w  If symptoms are not improving and are impacting daily

function w  Failure to return to baseline w  Inability to demonstrate improvement with ImPACT testing w  Academic/Vocational/Sports Impact

•  Affecting independent home management •  Affecting academics/grades •  Affecting work performance •  Unable to return to play

MANAGEMENT OF SYMPTOMS

Ø  Rest Ø  Education (Symptoms & Expected Positive Recovery) Ø  Stress management interventions

w  Sleep w  Relaxation Techniques (minimize stressors) w  Minimize use of stimulants (alcohol, caffeine, tobacco)

Ø  Graded/Modified return to activities (work, school, activities, sports) w  Modified schedules with additional time for task completion w  Environmental modifications

Ø  Monitoring recovery w  Physician follow-up w  ImPACT Testing w  What if the person is not progressing??

SPEECH THERAPY

Cognitive areas addressed:

Ø  Attention Skills

Ø  Memory Function

Ø  Problem-Solving

Ø  Reasoning Abilities

Ø  Processing (Accuracy/Speed)

Ø  Word Retrieval Skills

Ø  Mental Endurance

Ø  Executive Function Skills

Speech therapy evaluation:

Ø  History of symptoms

Ø  Clinical Interview

Ø  Cognitive assessment w  Standardized/Non-standardized

assessments

w  Task/Skill Simulation

w  Effects of cognitive demands on physical performance

w  Effects of physical demands on cognitive performance

SCIENCE OF THE BRAIN

Ø  Our brains read, think, remember and process information all day, every day, which is why functioning with any cognitive weakness at all can be exhausting.

Ø  Brain training rewires the brain so that it can function faster and more efficiently.

Ø  Traditional cortical parcellation schemes have emphasized the presence of sharply defined visual, auditory, and somatosensory domains populated exclusively by modality-specific neurons (i.e., neurons responsive to sensory stimuli from a single sensory modality).

Ø  Contemporary neuroscience research suggests that cognition is the result of a number of large scale brain networks that require efficient brain rhythm or synchronization.

THE BRAIN

PRIMARY NETWORKS OF THE BRAIN: Ø  Default mode network

w  What your brain does when not engaged in specific tasks. (REST)

w  The unquiet or noisy mind

Ø  Salience network w  The controller or network switcher w  Requires efficient neural timing

Ø  Central-executive network w  Engaged in higher-order cognitive

and attentional control - THINKING

NEURAL TIMING OF BRAIN NETWORKS: Ø  Synchronization between the

three major brain networks

Ø  Synchronized milli-second based communication between and within these networks

Ø  If compromised, efficient and normal cognition and motor behavior can be compromised

BRAIN TRAINING

Ø  Effectiveness directly and indirectly facilitates the synchronization between the brain networks

Ø  Strengthens the ability to invoke the salience network (controller) w  Learning to suppress/inhibit/silence the REST-producing brain network to exert

more controlled attention and thinking

SCIENCE OF IM & WHY IT WORKS Ø  Rhythm based brain timing therapies help repair or develop efficient

neural pathways

Ø  Sensory Stimulation increases cortical reorganization

Ø  Brain timing changes your capacity to think and learn

ATTENTION

Ø Attention Skills: w  Sustained Attention is the ability to stay focused and on-

task for a period of time. •  Vigilance - defined as the ability to maintain attention and

alertness over prolonged periods of time.

w  Selective Attention is the ability to quickly sort through incoming information and stay focused on one thing in spite of distractions.

w  Divided Attention is the ability to multi-task.

ATTENTION TRAINING

Ø  Therapy activities w  Recite sequences w  Specific listening w  Integrate pieces of information

– integrated spelling w  Mental Manipulation

Ø  Complexities/Demands w  Information w  Duration w  Environmental distractions w  In conjunction with IM

Ø  Integrating IM with Attention tasks w  Simultaneous completion of IM

timing tasks with attention task •  Present/exchange information in

time •  Present/exchange information off

time

w  Auditory Stimuli •  Spoken information

w  Visual Stimuli •  Written information •  Visual organization component

IMMEDIATE / WORKING MEMORY

Ø This skill handles the dynamic job of keeping the information you need to complete immediate and short-term tasks at the forefront of your mind.

Ø Working memory can be thought of as the equivalent of being mentally online, our search engine. It refers to the temporary workspace where we manipulate and process information.

IMMEDIATE / WORKING MEMORY TRAINING

Ø  Therapy activities w  Repetition of digits spans, word lists,

info •  Straight repetition, reverse,

alphabetical, order, ranked, sequenced •  Alternate orders

w  Mental math •  Math Tree

w  Alpha-Numerical Sequences w  Mental Manipulation

Ø  Complexities/Demands w  Information w  Duration w  Environmental distractions w  In conjunction with IM

Ø  Integrating IM with Memory tasks w  Simultaneous completion of IM

timing tasks with memory task •  Present/exchange information in

time •  Present/exchange information off

time

w  Auditory Stimuli •  Spoken information

w  Visual Stimuli •  Written information •  Visual organization component

PROCESSING

Ø  Processing (Speed): This is the accuracy and speed at which your brain processes information. Faster processing speed means more efficient thinking and learning.

w  Auditory Processing: This is the ability to analyze, blend and segment sounds. Auditory processing is crucial not just for speaking, but also for reading and spelling. This is because when you read, you need to be able to identify the individual and blended sounds that make each word unique and recognizable.

w  Visual Processing: This is the ability to perceive, analyze and think in visual images. Visual processing is imperative for reading, remembering, walking, driving, playing sports and literally thousands of other tasks you do every day.

PROCESSING TRAINING

Ø  Therapy activities w  Generate words from letter given

•  Letter before/after the letter given, two letters before/after

•  Timed tasks (all letters of alphabet) •  Visual selective attention/processing

activities

Ø  Complexities/Demands w  Information: familiar, unfamiliar,

related, unrelated w  Duration w  Environmental distractions w  In conjunction with IM

Ø  Integrating IM with Processing tasks w  Simultaneous completion of IM

timing tasks with memory task •  Present/exchange information in

time •  Present/exchange information off

time w  Auditory Stimuli

•  Spoken information w  Visual Stimuli

•  Written information •  Visual organization component

WORD RETRIEVAL / FLUENCY

Ø Word Retrieval difficulties may be associated with storage, retrieval, or a combination of storage and retrieval of words. w Difficulties with storage can be related to storage

of the word meaning or storage of the phonological representation (i.e. syllable and sound structure) of the word.

w Difficulties with retrieval can be related to retrieval of the word meaning or retrieval of the phonological representation of the word.

WORD RETRIEVAL / FLUENCY TRAINING

Ø  Therapy activities w  Word ladder (auditory or

written) w  Synonyms, antonyms w  Multiple meaning words w  Word scrambles

Ø  Complexities/Demands w  Information: familiar,

unfamiliar, related, unrelated w  Duration w  Environmental distractions w  In conjunction with IM

Ø  Integrating IM with Word Retrieval tasks w  Simultaneous completion of IM

timing tasks with memory task •  Present/exchange information in

time •  Present/exchange information off

time

w  Auditory Stimuli •  Spoken information

w  Visual Stimuli •  Written information •  Visual organization component

PROBLEM –SOLVING & REASONING

Ø Logic and Reasoning: This is the ability to reason, form concepts, and solve problems using unfamiliar information or new procedures. It enables you to create correlations, solve problems, plan ahead and draw conclusions.

EXECUTIVE FUNCTION SKILLS

Ø  The term executive function describes a set of cognitive abilities that control and regulate other abilities and behaviors. Executive functions are necessary for goal-directed behavior. They include the ability to initiate and stop actions, to monitor and change behavior as needed, and to plan future behavior when faced with novel tasks and situations. Executive functions allow us to anticipate outcomes and adapt to changing situations. The ability to form concepts and think abstractly are often considered components of executive function.

REACTION TIME

Ø  Brain timing - related to the integration between the two hemispheres of the brain

Ø  Slower brain processing speed is manifested in motor skill deficiencies Ø  The greater the balance requirements, the faster the brain must

process Ø  When we observe movement, we can indirectly observe the efficiency

of brain processing w  Smooth, coordinated movements are the result of precise timing and good

integration between the two sides of the brain w  Rigidity, and uncoordinated movements are the result of bad timing and faulty

integration and are indicative of poor brain processing

The inefficiencies that result from poor brain timing or slow reaction time are improved by performing activities that refine and repair the timing processes in the brain.

COGNITIVE THERAPY WITH IM

Ø  Your brain needs just as much exercise as your body

Ø  You can use IM with anything and everything!

Ø  When in doubt, try it out!

BUT WAIT, THERE’S MORE…

Ø  Want to earn CEUs for a FREE course on Reconnecting After Concussions? For this course, visit

https://secure.interactivemetronome.com/NetSite/IM/CEU/SimpleRegistration.aspx?course_id=1838.

Ø  While you’re there, be sure to check out

our catalog of 90+ webinars. Want more courses for about brain injuries? Great! We’ve got you covered. Autism? Reading? Using IM in Schools? Sports Rehab? We’ve got those too! Our catalog is divided into specialized bundles that let you tailor IM to your practice. Now, it is easy to get the information you want…and fast!