Cognitive Therapy for Concussions/Mild TBI
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Episode
Kate Grandbois: Hello everyone. Welcome to S L P Nerd Cast. We're so excited for today's episode. We are here with our expert guest, Jenny Traver. Welcome
Jenny Traver: Jenny. Thank you so much for having me today,
Amy Wonkka: Jenny, you're here to discuss current research and best practices in concussion slash mild TBI care. Now, before we get started, can you please tell us a little bit about
Jenny Traver: yourself?
Absolutely Amy. So I am a speech language pathologist and a brain injury specialist just outside of Boston. Um, I have a virtual private practice where I provide virtual cognitive therapy and executive function coaching. So I spend all day thinking about the cognitive side of things in our S L P world.
And that is why I'm here today to talk to everybody about cognitive [00:05:00] therapy and how we can better support our students with concussions and traumatic brain injuries, especially as they're getting back to school. So in my practice, I, um, do a few things. I provide direct therapy, uh, I provide coaching for families to make sure all their questions are answered.
And I also. Provide education to other professionals and school teams, um, including SLPs. Um, I'm actually quite excited this fall I will be hosting a course all about helping students get back to school with a concussion. So stay tuned for more about that because, um, I'm quite excited about it and in fact, a lot of what we'll be talking about today will, uh, be a part of that course as well.
So really, my goal today is my goodness to see how much information I can pack into an hour for you all, um, to help shed some [00:06:00] light on, up to date concussion information and debunk some of these concussion myths that are still out there floating around. And highlight the role of the S L P and what we can do to support our students with concussions, um, because more awareness is needed about our role and why we deserve a seat at this concussion table.
So thank you for having me today, and I, I can't wait to dive in. We're
Kate Grandbois: so excited to learn from you. For everyone who is new listening to this podcast, this is actually Jenny's second episode with us.
You've been with us once before talking about individuals with A T B I transitioning back into a school setting, and that was incredibly helpful and I'm, we're so excited for you to launch your learning platform and have more resources available for SLPs. We will be sharing all of that information with everyone listening.
For now, I need to get through our learning objectives and disclosures, so I will read those [00:07:00] quickly before we hop right on in learning Objective number one, list at least two key signs and symptoms of a concussion slash mild tbi. Warning signs and recovery timelines learning objective number two, describe the role of the SS l P in concussion slash mild TBI care and learning.
Objective number three, describe how cognitive therapy plays a role in the concussion slash mild T B I recovery process.
Disclosures, Jenny's financial disclosures. Jenny is the owner of a private practice called Cognitive, S l p, and is also an instructor at Emerson College.
Jenny also received an honorarium for participating in this course. Jenny's non financial disclosures. Jenny is a member of Asha and the AC and the Academy of Brain Injury Specialists.
Jenny also manages the social media accounts for her private practice. Cognitive SS l P. Kate, that's me. My financial disclosures. I'm the owner and founder of Grand Bot Therapy and Consulting, L L C, and Co-founder of S L P [00:08:00] ncast, my non-financial disclosures. I'm a member of Ashe SIG 12, and I serve on the A A C Advisory Group for Massachusetts Advocates for Children.
I'm also a member of the Berkshire Association for Behavior Analysis and Therapy. Amy,
Amy Wonkka: that's me. My financial disclosures are that I am an employee of a public school system and co-founder of SS l p Nerd Cast, and my non-financial disclosures are that I'm a member of asha. I'm part of Special Interest Group 12, and I participate in the A A C advisory group for Massachusetts Advocates for Children.
All right. Good stuff coming up. Jenny, why don't you start us off by telling us a little bit about why you wanted to talk about concussion and mild T
Jenny Traver: B I with us today? Thank you, Amy. I think the first thing, aside from how passionate I am about this topic, the first thing that comes to mind is that we don't learn enough about this.
Graduate school. In fact, if your [00:09:00] experience was similar to mine, you had a traumatic brain injury course where perhaps you learned a little bit about concussions or traumatic brain injury, and a little bit about the pediatric population in one segment of this course, Um, and it really deserves more time and attention, especially when we consider the fact that about 80 to 90% of traumatic brain injuries every year are mild traumatic brain injuries.
Also known as concussions. So it really deserves more of our attention, especially when we look at the research. It shows that this connection between the medical system and the school system is how we can best support our students when they get back to school. And being able to bridge this gap between the hospital and the school systems, being able to support the child and the family as they return to school and.
Is really what's gonna give this child their, the [00:10:00] ability to reach their learning potential long term. So it's a topic that really more awareness, as I said earlier, more awareness is needed about the SOPs role in this topic. And there's so much that we can do, so much that we are uniquely qualified to do to help these students.
Um, and that's what I. I wanna
Kate Grandbois: start by pointing out, um, a question that I had even before we hit the record button, which is that concussions and mild T b I are the same thing. I know nothing about this, so I'm very new to this topic and I didn't know that.
Jenny Traver: Thank you for bringing that up. So concussions are in fact a type of traumatic brain injury known as mild traumatic brain injury, and it's a bit of a, a misnomer in a way because.
Even though we call it a myo traumatic brain injury, the effects can be quite debilitating on a student physically, cognitively, and [00:11:00] emotionally. Um, so when we think about traumatic brain injuries, we wanna think back to any bump, blow or jolts to the head that can really cause the head and the brain to move rapidly back and forth.
That can cause. The neurons to stretch and the brain cells to be damaged and chemical changes in the brain to occur. So when we have a mild version of this traumatic brain injury, um, we might not actually seek medical care. Initially. You might not be going to the hospital like you would be if you had more of a moderate or severe brain injury.
And that's part of the challenge is that a lot of the mild TBIs and concussions. Might not reach a medical provider, might not be going to the emergency department. Um, however, medical care should be sought out, right? Because all concussions, all traumatic brain injuries should be taken [00:12:00] seriously. And there's a lot that we can do to help this recovery process, even if it seems like it's just a little bump
Kate Grandbois: to the head.
Little bump to the head. I, uh, this is making me wanna tell a personal story. My daughter fell down the stairs a few years ago. She's fine. I will preface with it all ended up okay. I wanted to take her to the emergency room and I had to, had to have an argument with my husband, who's wonderful and lovely.
So this is not a throw under the bus story, but it sort of is. He was like, it's not a big deal. She doesn't need to be seen. And I was like, she just felt this is you. She just fell down the stairs. We have to take her to the emergency room. And I remember having this argument because he felt like, eh, it's just a bump to the head.
And I, while I preface this with, this is not a throw of the bus story, even though there goes the bus and he's under it. I feel like there are a lot of myths about T b I just like that. I mean, just that you don't really need to go seek medical care unless you can't remember your name [00:13:00] or can't see or don't know what day it is.
You know, these things that we see in the movies. Do you feel that those myths still persist? I mean, outside of my household where I've
Jenny Traver: clearly corrected the problem. There are so many myths that are still out there. Um, I think the first, first, I'll address a few comments that you just made in your story.
Um, the first one being that even if you don't go to the emergency department, you should certainly reach out to your primary medical provider, whether that be the pediatrician or your P C P. Um, And do a full workup, right? Have them take a look neurologically at what's going on, and if they observe or notice any symptoms that they'd be concerned about.
Second from that is there are some warning signs that you can be on the lookout that will tell you when you should definitely go to the emergency department or call 9 1 1. And those are more of what you see in the movies, right? Those are, if you see, um, repeated [00:14:00] vomiting or nausea, slurred speech, confusion, uh, weakness, a sudden headache that keeps getting worse.
Um, any sort of loss of consciousness or seizures that are occurring, all of these would be an indication that more severe medical, sorry, that more medical care is recommended, um, because it could be a sign that, uh, more severe brain injury is present. So if you do not see these warning signs still go to your pediatrician, your P C P, um, and you'll notice a lot of the symptoms.
Um, really fall into four major buckets. Physical symptoms, cognitive symptoms, emotional symptoms and sleep. Changes in sleep. So physical you might see those. Headaches, lightheadedness, dizziness, sensitivity to light and sound. Um, neck pain, blurry vision. [00:15:00] We hear a lot about these physical changes. The second bucket of cognitive changes.
You might notice memory changes, um, difficulty paying attention or concentrating. Complaints, some brain fog zoning out a bit more than usual, having trouble remembering words or finding the right words, difficulty making decisions, and that's the cognitive realm and that's why we're here today, right?
This, for everyone listening, this is when we want to get involved, right? This is when the S L P should be on the team, and we should be getting a closer look at what's going on cognitively. The emotional piece is, um, you might notice some changes in mood. Uh, more irritability or sadness come up, depression, um, changes in personality even.
And then sleep disturbances is the last category, and that's difficulty falling asleep, staying asleep, sleeping at weird times. So these might be, [00:16:00] these are common signs and symptoms that you would expect to see after a concussion. Um, now, Back to your original question, um, about the myths out there. My goodness, there are so many myths, and I'll highlight a few in particular.
One, again, relates to your story, which is that we just need to give it time and the concussion will heal to just give it time. Now, in many cases, the majority of concussions and mild TBIs will. Heal right within a couple weeks, let's say two to four weeks. However, getting early care with a skilled concussion provider, it's is what's going to reduce the likelihood of prolonged symptoms.
Right, so a concussion provider can help identify these common signs and symptoms, can provide that education about the [00:17:00] warning signs even, and guide you as you meet with your medical provider, go back to school, slowly, increase activities and things like that. Another common myth, Is to stay in a dark room until symptoms resolve.
And this, I've heard this myth. Yes. So this used to be so, so popular because that's what the research used to tell us, right? Because the research is always changing, which is why we need to stay up to date. So this idea of staying in a dark room sometimes is referred to as cocooning. Cocooning in a dark room until symptoms subside.
And now we know that this idea of complete rest of doing nothing in a dark room actually hinders our progress and might prolong recovery. What we want to do is to do [00:18:00] more relative rest, which is rest for the first day or two, and then gradually re-acclimate to our physical and cognitive activities, monitor our symptoms.
Expect. Expect a symptom exacerbation because that's normal. We'll see the symptoms increase slightly as we reintroduce activities, but we want to be reacclimating so that we don't make it harder on ourselves later when we've spent so much time away from all the stimulation that's causing this trouble.
Kate Grandbois: I have a question. What about the myth? Or maybe it's not a myth. I don't know. Uh, don't fall asleep. You have to stay awake because if you fall asleep, you're gonna go into a coma. And, uh, you know, you see cartoons of like people in showers, like, just like try throwing water in people's faces, trying to get them to stay awake.
Is that true?
Jenny Traver: So this, um, [00:19:00] For the first four to six hours after you have a T B I, you a mild T B I or concussion, you wanna be monitoring for symptoms and monitoring for those early warning signs that I mentioned after that four to six hour period, you want to be prioritizing sleep. Sleep is what helps the body and the brain heal.
So you do not need to be staying up for a full 24 hours afterwards, but keeping an eye on those symptoms early is key. Same with, you know, not taking medications right away because we wanna see what the symptoms are, right? We wanna make sure we understand what's presenting, because that's gonna guide us in what type of care we need, how emergent the care might be, and who we wanna start getting involved on our team.
Amy Wonkka: So an observation I have as you're going through some of these myths, it's just not only that the myths are incorrect, but in a lot of these instances, [00:20:00] what the myth tells you is the exact opposite of what you're actually supposed to be doing. So the myths are not only. Not accurate. They're super misleading and could lead a patient to do the completely wrong things.
I, I'm wondering, as an SS l p, how, how soon are you seeing patients in this process? And I'm like jumping like a little bit out of order, but
Jenny Traver: like if you are,
Amy Wonkka: if you are working with people, are you seeing them ever in these like initial stages or are you helping guide people through, Hey, this isn't, don't, don't put yourself in the cocoon.
Don't do it. It's not
Jenny Traver: good for you. So that's a great question, Amy. I'm, I'm starting to see more as I am raising more awareness about some of these concerns and sharing the research, what the research says. Um, often people will reach out to me when they're getting back to school, and that's, that's the initial point of contact when the S L P [00:21:00] could get involved and really be supportive.
Um, so. But really we want, as early as we can get a concussion provider involved, the better. That might not be us, that might be a physical therapist, that might be a, a medical provider, but somebody who's seen a lot of concussions and TBIs, um, who can guide this healing process is, is really helpful. So as early as two weeks, as early as two weeks, I've seen patients.
Typically cognitive therapy wouldn't begin until that, um, four weeks or later. But in those early stages, we can be doing more of the brain health and education understanding of concussion, dispelling these myths. Um, so really focusing on the education piece and then also helping with the school reentry piece, right?
Being able to support the student in getting back to school and identifying accommodations. Um, that piece starts early and then the longer term support is, [00:22:00] is, um, more of the cognitive therapy. And I know we'll be talking more about this later as well, but great question. That
Kate Grandbois: leads me to my next question, which is sort of starting to talk about the role of the SS l p in all of this.
You've mentioned cognitive therapy. This is something that I learned in graduate school almost 20 years ago and don't really remember anything about it at all. Um, I have to imagine that there are many professionals who are supporting these patients. You've, you've mentioned the term concussion specialist or what, what was the term
that
Jenny Traver: you used?
Uh, skilled concussion provider, I think skilled concussion
Kate Grandbois: provider. Right. So I have to assume that there is a, there are, there is a group of individuals who are likely supporting these individuals two weeks out, four weeks out, et cetera. Can you talk to us, before we get into the role of the s l P, can you talk to us a little bit about the kind of supports and the kind of care that these [00:23:00] patients need when they're ready for care?
Jenny Traver: Absolutely. So the first point of contact should be a medical provider, right? So reaching out to your primary care physician or pediatrician, um, would be the first step to do a full evaluation and workup and, and determine what the signs and symptoms are, determine if we need any specialists involved early on, and really begin that conversation about what.
We what the recovery plan will be, right? What the next couple weeks look like. Um, they will also be able to start the conversation with the school and provide you with information about do's and don'ts of what exercise you can do, what you can, and, and how to slowly increase your return to school. After that, it's really gonna be based on your symptoms and what's presenting.
So for example, if you have a lot of physical symptoms, we wanna get a physical therapist involved. And it [00:24:00] depends on what physical symptoms you're showing, on what type of physical therapist we would want. So this goes back to that idea of the skilled concussion provider. Is, we're not looking for a generalist here.
We're looking for a physical therapist that's skilled in the neck, if that's the pain you're having or skilled in vestibular therapy, if you're feeling dizzy and having trouble balancing or feeling that lightheadedness. Um, so, and, and again, if we see the cognitive symptoms come up, that's when we wanna get the cognitive therapist involved.
But another big piece aside from the, the doctors and the rehab professionals is the school team now, everyone's school team is, it's functions slightly differently. Their concussion protocol. It differs based on what school you're in. But often your school team will involve a combination of your school nurse, um, a learning specialist, um, maybe your [00:25:00] athletic trainers or coaches, depending on what age you are and your teachers and guidance counselor.
Right? And again, building this team and this communication between these professionals is what we're aiming for, because that's, That's really what the gold standard is in concussion care is this interprofessional team approach where collaboration flows seamlessly through all of these numbers. Um, and the s l p, whether this is as a rehab professional or the s l p in the schools, um, ideally both so that we can be communicating would also be involved.
Kate Grandbois: Thank you for that. It's making me think about just some barriers to communication, just because indirect service and um, extra time to communicate can be such a challenge. So maybe at some point towards the end of this conversation, we can talk about ways to overcome or some strategies to overcome some of [00:26:00] those barriers.
But for now, I wonder if you could talk to us a little bit about. The SLPs role in all of this? I mean, I just thinking about our scope of practice being so wide, I could imagine that our role could really differ depending on the presenting symptoms. Is that an accurate assumption? Um, yes.
Jenny Traver: Yes. Uh, when we're providing care, like in any area of our field, it certainly will differ depending on who's sitting in front of us.
I said, I think there are big picture categories that we can think about. That will help us all provide better care for this population. So the first one being that education, right? That psychoeducation that happens early on in the recovery process. Um, being able to help somebody understand what is going on in their brain, what, how the healing process might look and feel like to them.
Uh, why they need to [00:27:00] be prioritizing rest, why things might be harder right now. But also holding that space for hope and, and a positive mindset about their recovery. Being able to say, this is hard now, but it will get better and we expect a really good recovery with this, but let's give it time, I think can be really, really big.
Um, especially when we look at the research which says that somebody's mindset about their recovery impacts their recovery. So I think that's the first role that we can play as SOPs is with the education around the brain, around cognitive communication skills, around, um, my goodness, what types of accommodations are important for students in school?
How we can support somebody's cognition and communication skills in the classroom setting. Um, and who else might be necess or who else might. Want [00:28:00] to join the team. Who else? We might want to join the team. I think I said that correctly. Um, so that's the first piece. The second piece of our role is, again, thinking about these, uh, symptoms.
So when the cognitive symptoms are spiking, when we see a lot of challenges with attention and memory and word finding, energy management is a big one. That's again, where we want the s l p to be involved. So we have the education as our number one. The second one is taking a closer look at this, uh, the cognitive skills, and I might even separate this further to say that early on it would be symptom and energy management.
So even things like helping somebody understand what the symptoms are and ways to track their symptoms can be huge, helping them. Understand their energy and, um, especially in the [00:29:00] recovery process when they're experiencing so much fatigue can be really helpful. Um, so that symptom and energy management systems can be a key part and key role of the S L P and then the specific strategy instruction for their cognition.
So finding ways to strengthen their attention in memory and executive functioning, whether this be with assistive technology, right? Introducing compensatory strategies like using a Google calendar or alarms and reminders on their phone to support their memory and organization. Um, or a pen to help them while they take notes.
That also records the what's happening in the classroom to help with note taking. Or to use more of a metacognitive strategy instruction approach, where we are directly teaching individuals to regulate their own behavior by monitoring their performance and um, identifying when [00:30:00] behaviors need to be changed to optimize their performance longer term.
So in summary, high level that brain health and psychoeducation, the symptom and energy management component, assistive technology and compensatory strategies for cognition, and then specific strategy instruction of your cognitive skills.
That
Amy Wonkka: was really helpful. Thank you for that. I, I am, as I'm listening to you talk and you're talking about, you know, kind of the four different key types of symptom presentation we might see with people who have a concussion, mild T b i. Um, I'm looking here in the notes you had sent over to us, and I'm wondering if that maps onto different types of concussion phenotypes.
Like are there. As an SS l p, who's doing this more often? Can you look at certain clients and think, oh, I think that you kind of fit into this type of profile where I anticipate supporting you
Jenny Traver: more in these different ways. [00:31:00] Thank you for bringing this up, Amy. So this, um, con, the concussion. Phenotypes is also not very well known right now, but there are in fact multiple types of concussion and those fall into seven main categories.
So one of them is cognitive. So often we are working with individuals that present with a cognitive concussion phenotype. That being said, there often individuals will have multiple types of concussions, so we might have somebody. That has cognitive difficulties, but also presents with changes in their mood and, uh, vestibular challenges, right?
Having trouble with balancing or dizziness, um, and having difficulty with their vision or their ocular motor. So that would be four different types of concussion, the cognitive, the, a mood, the vestibular, and.
So [00:32:00] this really, we use the, the seven different types of concussions to help us identify what's going on with our client and build our team, right? Identify who else, what other providers should be part of our team and where they're trying to get to the root cause. So if I see somebody with a headache, for example, I'm not quite sure why they're experiencing that headache.
So I wanna do a screen to figure out if the headache is simply be, or just because of the cognitive challenges, or if it could be due to neck pain, right? A cervical component, in which case I want a cervical PT to look at that. Um, or if it could be due to sensitivity with light in the room or when you're reading something, which might be more of a vision component, um, or if it's something completely different.
They didn't drink enough water that day, and that's more of the brain health and [00:33:00] education that we wanna look at.
Kate Grandbois: You mentioned four phenotypes. I gonna see if I can repeat them back to you and then maybe you can tell us the other three, or maybe I didn't, maybe I didn't catch on this. Okay. So you mentioned cognitive, vestibular, ocular motor. Uh, I'm not
Jenny Traver: really remember the fourth one.
That's okay. Effective or mood? Oh, mood.
Kate Grandbois: Mood. And
Jenny Traver: then what are the last three? So I mentioned cervical two, so that's the neck component. Gotcha. Um, pain and then headaches actually is one of the categories as well. Really? So there's overlap. Yes. So that's, so that's the seventh. Um, and then the first one is physiological or autonomic.
And that's when we hear more about the, um, exercise intolerance or changes in your heart rate variability. Interesting nervous system. So what, what's interesting about these [00:34:00] seven is that there is a lot of overlap, which again, is why we wanna be understanding the root cause and really working with a concussion provider to make sure we're treating the root cause and not just the symptoms.
And often we will see people who have multiple phenotypes of concussion.
So when
Amy Wonkka: we think about recovery from concussion, I know you mentioned one of the myths was if you just wait it out, you'll get better. And sometimes that's true, but sometimes not necessarily. And in any regard, having somebody to support you through the process is going to be beneficial. Are there other.
Are there risk factors that people who do this regularly are able to identify that might make it more likely that you'll have a longer recovery or a more challenging recovery?
Jenny Traver: Absolutely. So typically, um, according to the research, [00:35:00] most people recover from their concussion within two to four weeks. That being said, clinically, I typically see more like one to three months.
Um, or longer. Now, the longer recoveries, as Amy's question gets at, is really for people who have these preexisting conditions that might make it more likely for them to experience a prolonged recovery. And those are things like a history of concussions, right? If they've had concussions in the past, um, and their recovery from those, if they were, if they actually went to a rehab professional or saw medical care, or if.
They just went about their life can play a role. Um, preexisting learning differences, um, or language differences. Um, mood disorders like anxiety of depression, and even a family history, either personal or family history of migraines can play a role in [00:36:00] prolonged recovery. So these, I often, um, again, this is one of the things that all of us SOPs can help with is identifying, um, when we meet with an individual who's had a concussion or might've had a concussion, making sure we ask these questions initially in our initial evaluation.
To help with that education piece and giving them a general recovery timeline can be really helpful. Um, especially if the concussion doesn't happen on school grounds. So sometimes we as professionals, especially in the school system, um, or in private practice, we might be the first to hear about changes with their attention and memory and schools all of a sudden harder, and we're not sure why.
Or we're having these headaches and we don't know what's going on. And I think that's when we can dig a little bit deeper as well to [00:37:00] figure out if there was an event, and then make sure the appropriate channels know about it, right? Making sure we let the, the team know, the family know, um, and make sure it's documented in the school records so that we can monitor this student longer term as well.
I
Kate Grandbois: have a question just about the collaborative process with all of this. I'm just thinking about SLPs listening who are interested in this line of work or, you know, maybe work in a school or work in private practice, and how much of this might really be, how much of our work as SLPs is enhanced through an interdisciplinary model.
I mean, you're talking about. You know, the cervical phenotype and wanting to get a specific kind of PT involved. How do you bridge some of these gaps given that this is, these are individuals who are not in a hospital, right? But at the same time, they need to be supported by an interdisciplinary team of [00:38:00] professionals that might not exist in a school setting or in a private practice setting.
How do you
Jenny Traver: do that? Oh my goodness. I, you know,
Kate Grandbois: that was not supposed to be a trick question.
Jenny Traver: I, I think the, my best advice is to always ask the questions of who else could be involved. Right? Always ask ourselves what is presenting in this student? Um, Who else could be a part of the team to help this student? I mean, one of the things, a lot of what I do when I first meet a student is ask a ton of questions.
Right? And I have, and for anyone listening, being like, but Jenny, what are those questions? Reach out to me because I will get you a list. But I have, um, but some of the ones I mentioned, right? Have you had concussions in the past? Have you experienced headaches [00:39:00] or migraines before? Um, you know, it can really help us understand what's going on with the student.
And it's always better to be proactive. So if we think that, you know, someone does have a history of mood, mood disorders, reaching out to, if they see a therapist, reaching out to them to try and collaborate or getting the school counselor involved early on can be really key. Um, right leaning on our team whenever possible.
So that they can ask questions that we wouldn't even think of, I think is, is the best advice I have, knowing, recognizing that this takes time and this takes effort. And, um, my goodness, we all, I, I wish we all had more time and, um, and abundance of effort to share.
Amy Wonkka: So Jenny, I've got a question. How, how do we know a student is ready to go back? I know that we've learned that we shouldn't just [00:40:00] be cocooning away in a dark room, and that it's a process where you are, you know, trying to expose the person to more of their regular life. Um, you kind of expect an exacerbation of their symptoms, but is there, is there sort of a process there in how to figure that out and kind of what our expectations
Jenny Traver: should be?
Absolutely. So those first two days after concussion is when we wanna prioritize physical and cognitive rest. So 24 to 48 hours after the concussion. And then we wanna start to introduce light activities at home. So activities of daily living, your normal routines of cooking meals, and eating meals, and going about your day.
And then introduce some cognitive activities, um, even some schoolwork, so some reading, and see how that goes. If you have worksheets available, do some light homework, um, to see how your symptoms are presenting [00:41:00] after we're able to do some of those activities at home. Increasing the symptoms too much, we can then go back to school part-time.
And it depends what that looks like for everybody. Um, usually it would be. An hour or two, maybe a few hours a half day, but a partial day at school, um, initially and with supports in place, right, with those accommodations, with the ability to take rest breaks whenever they need to. Um, I often say access to a quiet space, whether that's the nurse's room or even your office or the guidance counselor's office, um, but some quiet space so that they can rest when they need to.
After the partial day at school, we can slowly build up to a full work day. Um, with accommodations. And then the last step is reducing those accommodations, and that's usually the [00:42:00] longest step. So when I mentioned that it takes a few months for many people that what I see clinically, they're still in school, but they're in school with accommodations, with a modified workload, a modified schedule in some way, um, when the ultimate goal is to get them back to school.
Full time with their full academic load and homework without the supports in place. So that's kind of the high level stages. Um, and in this process, as we move from one stage to the next, we would expect to see some symptom exacerbation, as I mentioned earlier. Right. That's quite common. Um, as we reintroduce some of these activities, If we see more than a mild symptom exacerbation, we wanna slow this process down.
So the way we can think about mild exacerbation is actually if we use the zero to 10 point scale, um, where [00:43:00] zero is no symptoms and 10 is the worst symptoms manageable. We don't want to increase by more than two points. If we do increase by two points, we wanna go back to where we were within an hour. So that's what we can use as mild symptom exacerbation, which is normal in this process if it.
If you do an activity and you feel two out 10 to start, and by the end of reading that page or paragraph you're at a five out 10 or six outta 10, then we're going too fast and we need to slow down before progressing to the next stage. And this idea of mild symptom exacerbation, it might be referred to as the two point rule, you might hear it as.
Um, but this was actually one of the things mentioned in this recent consensus statement that I wanted to share with you all. This was a statement that was, um, [00:44:00] So this was actually one of the things mentioned in the most recent sports concussion consensus statement that I wanted to share with you all. So this was back in October of 2022. The sixth International conference on concussion in sport was held in Amsterdam. And 31 expert panelists representing multiple disciplines from nine different countries, including the US gathered to develop this new consensus statement on sports concussion, and it was just released in June of 2022.
Now, this paper, I would highly recommend to anyone listening who's interested in this population because they do a wonderful job of dispelling a lot of the myths. I mentioned today and some more, um, and they mentioned this two point rule. They de define for the first time in research what this mild exacerbation looks like.
And they say that when we go [00:45:00] past mild exacerbation is when we need a slow down this return to learn process. Um, so I'll send Amy. And Kate this, uh, the report. You can read the research article. I also have a blog post that I wrote about the key takeaways for those that are. So busy with time, as limited as I know it is for so many of us.
Um, but in this article, you'll be able to read a lot of the new research out there, um, and you'll be able to see the new, uh, sports Concussion Assessment tool and the the Sports Concussion Office Assessment Tool. And these can be used both on the sidelines. But also in the office, um, in private practice after concussion.
So this is the sixth edition that, so I'll make sure to get you all of these resources.
Kate Grandbois: That would be awesome. Thank you.
Okay, so
Amy Wonkka: I'm an S L P I. Let's say I'm working in the [00:46:00] schools. I have a student, they've had a concussion. They're coming back to school.
Jenny Traver: What, how do I help them? So early on, um, advocating to be on the team mm-hmm. Reaching out to see what's, what symptoms are present is key, and helping with the team's initial creation of these accommodations.
And I wanna point out at this point that, you know, these accommodations early on are temporary. So they're often not written into a 5 0 4 plan or created a more formal process through an I E P at this stage. That being said, One of the roles of the SS l P can really be to support the student in identifying what accommodations are helpful and when we can modify them longer term, and ultimately whether we need to make this more [00:47:00] formal, which might be the case, especially for some of our individuals who perhaps were.
Had some under underlying difficulties before that weren't necessarily diagnosed or, um, noticeable to their performance, but are now quite affecting their learning, um, and overall performance in school. And that's when we certainly, that shift is key for us to be able to provide more support in the school system.
And helping our colleagues monitor that progress, uh, is, is key to determine, you know, when we modify, when we add, when we subtract, and how to keep them moving in their recovery overall. Do you have
Kate Grandbois: any suggestions for. Terminology or statements that, um, SLPs could use to advocate to be on a team? For someone who's returning with a T B I, [00:48:00] do you find that to be a difficult process or something that requires a lot of advocating?
Jenny Traver: Hmm. It can. Um, it really, it really depends on your school setup. Um, there. Their willingness and, and the foundation they have to collaborate and provide this interprofessional care. I also think that this is an opportunity for education. Um, being able to explain what the research says about concussion, um, using that.
Article that I just mentioned will be huge, will be huge. So please look in the notes for that. Um, to really show them what the research says and what our role of an SS l P is, uh, and how we can support an individual, I think is, is the first step. Um, and finding creative ways to, to provide support, um, you know, I think can [00:49:00] be quite helpful.
I, I also, you know, wanna mention that there is this wonderful referral tool that we can all use, um, that's called the cognitive communication Checklist for acquired Brain Injury. And this can be a, a great way for us to quickly show our teammates. Um, or hand out to the family to have them identify if there are any cognitive or communication differences since their brain injury.
And help to, uh, point out the need for cognitive communication support through an SS l P. So this tool is actually created by Sheila McDonald's. Um, for who's an SS l p, um, specifically to help families describe what they're experiencing after brain injury and [00:50:00] help healthcare professionals and administrators understand, um, how to detect a communication difficulty and refer to a speech language pathologist.
And it's quite a wonderful tool. Um, we can link it as well for you. Um, but it's a free tool that breaks down difficulties into categories of auditory comprehension, expression and social communication, reading comprehension, written expression, um, and then thinking and executive function skills. And it's a quick checkbox, you know.
A quick checklist where you can have, again, whether the family fill it out or the teachers fill it out so that you can better screen for individuals who might need your support more directly. I was just wondering
Amy Wonkka: when you're, because you are in private practice and you're supporting families, you're supporting students who are returning to school,
Jenny Traver: um, When, when
Amy Wonkka: you're having a really successful team experience for a student, can you just talk to us a little bit about what that [00:51:00] looks like?
And I'm sure it will be different for every student, it will be different for, you know, their unique recovery phenotype, but, um, as, as a student is going back to school, are there patterns where you're like, oh, it's, it's super helpful. If we have the nurse and the classroom teacher and the speech pathologist, are there any trends that that might be helpful for our
Jenny Traver: listeners?
I. Hmm. Um, absolutely. So I think the first one is early communication with the medical provider would be key. Um, and understanding the, the concussion management team at the school, because it varies. Yeah, it varies. And it's not always as interdisciplinary as we are hoping and pushing for. Our advocacy efforts, um, understanding who is involved and then based on what we're seeing, making recommendations for who else should be on the team.
So what this would look like is early communication with the doctor. [00:52:00] Um, Communication with usually the learning specialist and or the school nurse, but usually learning specialist and or the school counselor to share what we're seeing. Um, and, and then depending on how the, the student is presenting, um, reaching out to, uh, trainers and, and, uh, coaches as well.
Amy Wonkka: I am just wondering as a speech pathologist or just thinking, I guess as a speech pathologist who has done a lot of school-based work, if you are listening to this podcast and thinking, okay, one thing I could do, you know, to maybe help make sure that I'm included in the thought process when we have students who are coming back after concussion mild, t b I.
It could be just form some relationships with the coaches. Like I know in most of the schools where I've worked, the coaches are also teachers in the school. Right? So perhaps it's just reaching out to those people, forming a connection, letting them know, as a speech pathologist, you're here maybe sharing the, I've forgotten the name of it.
Now, [00:53:00] sharing that tool, the C C C A B I, um, you know, with those different school-based providers. Who might be more likely to be part of that team might make it more likely for you as the S L P who's working in the school to be invited to sort of support those students.
Jenny Traver: So for when we're thinking about what this great communication and interprofessional team looks like, um, it really involves the collaboration between the medical system, uh, the school team, and then other rehab professionals.
So if you're the outpatient s l p, getting in touch with the school, SS l p would be wonderful to share some knowledge and support with them. Um, if you are the rehab part of the rehab team, being able to communicate with the medical providers and the school, um, the point person in the school, since we did mention that those.
Each concussion protocol is varies per school, and their concussion management team might look very different. [00:54:00] Understanding what your school's team looks like and who the point person is, whether that be for the team or for this individual student as they return, will help you to figure out who to share this information with.
And as Amy mentioned, you could share the cognitive communication checklist with them. You could share some. You could share the consensus statement on sports concussion to debunk some of these myths and highlight the current research on concussion care. And of course you could highlight our, um, our role as SOPs in cognitive communication skills in general.
I
Kate Grandbois: have one last question before we wrap up, and it is related to something you said in the lab in when we during, when you answered the last question. Is working closely with the families. I have to assume that some of the families that you're working with, you know, they're dealing with [00:55:00] a, something that was unexpected or something that creates a lot of fear, or on the other side, oh, it's no big deal.
It was just a bump on the head. Do you find that counseling tends to be a big piece of this, particularly in the beginning when you're doing some of this foundational education?
Jenny Traver: Counseling and education. Absolutely. Um, and again, it's really helpful to share what the research says about the recovery timeline, about the how Most students, more than 75% of students require accommodations initially.
So again, being able to validate, um, and normalize some of these. These things can be really helpful when working with families. Um, and then of course, taking some of the stress off of their shoulders by facilitating this communication and collaboration is one of the, I, I would say the biggest ways that I support families early on is to, to really [00:56:00] triage this communication and say, these are the people we need to get involved.
These are the questions we're gonna ask. I'm gonna call these people first and let you know, you know, and again, that's part of the. Uh, luxury that I have of being in private practice and, and in private pay. Um, not being, you know, dictated by insurance that I can spend more of my time, uh, providing this support for the families, provide this counseling and education and, um, communication between key team players.
Thank you
Kate Grandbois: so much for sharing all of your knowledge with us. Do you have any parting words of wisdom or anything else you'd like to leave our audience with before we say goodbye?
Jenny Traver: Absolutely. I think, my goodness, I, I would say if you're feeling. Whether you're feeling inspired or overwhelmed by this information, please know that you are not alone.
There is so much to learn out [00:57:00] there. There's so much that we can be doing, but let's support each other in doing this and, and this is really one of the main reasons I'm creating this. Course in community on helping students get back to school with a concussion, because I wanna better support parents and families.
I wanna support other SLPs, other educators and rehab professionals to really get this information out there. So if you are listening and you're excited to learn more, or you're feeling like you're overwhelmed by all of this and want, um, some more, a slower pace of a conversation perhaps, or more handholding in this process.
Please reach out. Please visit my website for more resources and consider joining us for the course this fall. I would love to have you, um, so that we can all stay up to date on concussion care and support our students and advocate for the role of the SS l p. Thank you so much, Jenny. Thank.
Kate Grandbois: Thank you. It, it was really, really wonderful to have you today.
Thank you so [00:58:00] much for being here. For everybody listening, we will link all of the resources in the show notes as well as on the landing page on our website. Thank you again, Jenny, for sharing all of your knowledge, and we hope to see you here
Jenny Traver: again soon. Absolutely. It was my pleasure. Thank you for having me.
Sponsor Outro
Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study.
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thank you so much for joining us and we hope to welcome you back here again soon.
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