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
 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
“Defined as a complex pathophysiologic process
affecting the brain, induced by traumatic
biomechanical forces secondary to direct or
indirect forces to the head.”
http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf
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



Brain rotates on axis causing
stretching/tearing of axon
Stretching and tearing of blood vessels
results in hematoma
Brain strikes skull causing contusion
Pathophysiology
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
Neurometabolic Cascade
Following Concussion/MTBI
500
(Giza & Hovda, 2001)
% of normal
400
Calcium
300
K+
200
Glucose
Glutamate
100
50
0
2
6
12
minutes
20
30
6
24
3
hours
Cerebral Blood Flow
UCLA Brain Injury Research Center
6
days
10
Mechanisms of Injury
Causes of TBI –all age groups
http://www.cdc.gov/TraumaticBrainInjury/causes.html Accessed May 30, 2013
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
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
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
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
Consequences of
Injury
Physical
Cognitive
Emotional
Sleep
Headache-71%
Difficulty concentrating 57%
Irritability
Drowsiness
Dizziness – 55%
Feeling slowed down - 58%
Sadness
Sleeping more
Fatigue -50%
Feeling mentally “foggy” 53%
More
emotional
Sleeping less
Balance problems 43%
Visual problems 49%
Sensitive to light 47%
Difficulty remembering –
43%
Nervousness
Trouble falling
asleep
Vomiting
Nausea
Sensitive to noise
Numbness/tingling
Dazed/Stunned
Forgetful of recent events
Confusion about recent
events
Answers questions more
slowly
Repeats questions
Most Common Symptoms
Reported by High School Athletes
80%
Headache
71%
70%
60%
50%
Difficulty Concentrating
58% 57%
55% 53%
Fatigue
50% 49%
47%
Drowsiness
43%43%
40%
Fogginess
Feeling Slowed Down
30%
Dizziness
20%
Light Sensitivity
10%
Trouble Falling Asleep
0%
Kontos, Elbin, French Collins, Data Under Review; N = 1,438
Difficulty with Memory
Risk factors for protracted
recovery (>3 weeks)
- Age - the younger the
longer the recovery
- Gender
- Repetitive
concussions
- Learning Disabilities
- History of migraines
and migraine
symptoms
- Report of dizziness at
injury
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)
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!
WEEK 1
100
90
80
70
60
50
40
30
20
10
0
WEEK 2
WEEK 3
WEEK 4
WEEK 5
80%
RECOVERED
60%
RECOVERED
N=134 High School
Male Football Athletes
40%
RECOVERED
1
3
5
All Athletes
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
No Previous Concussions
1 or More Previous Concussions
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.

https://www.revisor.mn.gov/laws/?id=90&year=2011&type=0
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?
 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:
Neurology
Neurosurgery
Neuropsychology
Nurse Practitioners
Nursing
Occupational Therapy
Physical Medicine and
Rehabilitation
Physical Therapy
Physicians
Psychology
Psychiatry
Social Work
Sleep Medicine
Speech Therapy
Speech Therapy
Erin Ingvalson, MS CCC/SLP CBIS
Cognitive Rest
 What is it?
 Is it important?
 How do you manage it?
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?
 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?
 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 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 Rest?
 Cognitive Activity Monitoring Log (CAM)
Gerard A. Gioia GA, PhD
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?
Main Players
 Neuropsychology
 Psychology
 Occupational Therapy
 Speech Therapy
**A team approach is most
effective
Supporting Players
 Physician
 Physical Therapy
 Therapeutic Recreation
 Social Work
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 SpeechLanguage Pathology?
Cognitive Communication
Deficit
 Word finding difficulties
 Difficulties with focus and
attention
 Difficulties with short term
and working memory
 Decreased processing
speed
 Difficulties with planning
and organization
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 should be flexible and guided by
patient factors, history, and chief complaints.
 Assessment should include a combination of
standardized and informal measures
Standardized Assessments
 Woodcock-Johnson Tests of Cognitive Abilities
 Oral and Written Language Scales
 Clinical Evaluation of Language Fundamentals
 BRIEF
 FAVRES
 Rivermead
**Kids can often do well on standardized tests yet
still demonstrate significant functional deficits
Informal Assessments
 Behavioral considerations
 Spontaneous discourse
 Patient and family complaints
Treatment of Cognitive
Disorders
 Education
 Individualized
 Context based
 Strategy training
 Partner training
Occupational Therapy
Candice Gangl OTD, OTR/L
Occupational Therapy
What does OT do after a brain injury?
Assist with handling changes to your day-today 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 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
 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
Vision
 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
 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
 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 829836
 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
domains include:
 Initiation and Inhibition
 Executive Dysfunction
symptoms a family might
note could include:
Cognitive
Flexibility/Shifting set
Lazy, doesn’t do anything
Working Memory
Saying things that are
inappropriate
Planning and Organization
Self-regulation/Monitoring
Repeating the same things
over and over
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
OT intervention model
Awareness
of Triggers
Maximize
function in
daily life
Fade
supports as
able
Ability to
follow simple
directions
Increased
cognitive
demand
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 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
Nicole LaBerge, PT ATP
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 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: 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 forever!
Physical Rest
Rest from Sports
Balance
 The body maintains balance from 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
 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
 Dizziness
 Loss of Balance
 Nausea
 Difficulty changing positions (head and body)
 Car sick
 Headache
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
 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
 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 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
Questions?
Contact Information
 David Everson, PT
 Rehabilitation Supervisor --Minnetonka
Clinic
 Gillette Children’s Specialty Healthcare
 Neuro Trauma Lead for Rehab Therapies
 DEverson@gillettechildrens.com
 Nicole B. LaBerge, PT, ATP
 Gillette Specialty Healthcare
 Lifetime Clinic St. Paul, MN
 nicole.laberge@gillettechildrens.com
Special Thank You to
Leslie Larson MS, RN, PHN, CNP- PC, CNP-PMHS, CBIS, CIC
Gillette Children’s Specialty Healthcare
---She completed some of the graphs in this presentation
• Erin E Ingvalson MS, CCC/SLP CBIS
• Speech Language Pathologist
• Gillette Children’s Specialty
Healthcare
• St. Paul, MN
• eingvalson@gillettechildrens.com
• 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)
• cgangl@gillettechildrens.com
Resource Slides
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 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
 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.