Project Description: My capstone project aimed to address occupational therapy’s role in mTBI management and rehabilitation, particularly persistent post-concussion symptoms (PPCS). A systematic review of the topic was initiated and guided the creation of evidence-based educational resources for clients and practitioners. Clinical experiences and the pursuance of specialized certifications led to gains in applicable knowledge for future clinical practices.
Areas of Study: 1. Clinical Practice, 2. Research, 3. Advocacy
My capstone was partnered with Cincinnati Children's Hospital Medical Center. Throughout my project, I was able to gain clinical experiences with the neurological pediatric population in acute care, inpatient, and outpatient rehabilitation. Additionally, I was able to shadow at the hospital's Brain Health and Wellness Center to better understand multidisciplinary care in mTBI management.
Mentors:
Expert Mentor: Alison Heinekamp, OTR/L, CBIS
Ali is an experienced occupational therapist with ten years of experience treating the pediatric population at Cincinnati Children's Hospital Medical Center. She has primarily worked in the inpatient and acute care setting, where she specializes in treating neurological conditions. Ali has extensive knowledge of traumatic brain injuries and hopes to further OT's role in pediatric mild traumatic brain injuries.
Needs Assessment
Current research was analyzed and experienced practitioners were interviewed to assess the needs of mTBI clients and occupational therapists working with this population.
Key Points:
- Occupational therapy has been found to be the least referred rehabilitation service (physical therapy, speech and language pathology, neuropsychology) by physicians for concussion management (Vargo et al., 2016).
- Salisbury et al. (2017) found that occupational therapists were less accurate in their knowledge of concussion management when compared to other multidisciplinary team members.
- Finn (2019) emphasizes the lack of literature supporting the role of occupational therapy in concussion management and the absence of clear guidelines for clinical practice.
Literature Review
A literature review was completed prior to the start of the capstone project to assess current practices in pediatric mild traumatic brain injury management and rehabilitation.
Key Points:
- After research and interviews with practicing professionals, concussion management is considered an emerging practice for occupational therapists. Recent changes in concussion protocol have facilitated this emergence. Before, the protocol was to have those with a mTBI halt all activities for two weeks. Research has demonstrated this protocol's poor social, physical, and psychological effects and advocates for a gradual return to meaningful activities (DiFazio et al., 2016).
- According to Lumba-Brown et al. (2018), 70-80% of all mTBIs resolve within one to three months. That leaves 20-30% of clients at risk of developing Persistent Post-Concussive Symptoms (PPCS). PPCS is a period where concussion symptoms are increased or unresolved outside the expected time frame and is when a multidisciplinary team is often recommended (McCrory et al., 2017).
- There are five clinical profiles and two modifiers of sleep and cervical disturbances: vestibular, ocular, cognitive/fatigue, posttraumatic migraine, and anxiety/mood (Kontos et al., 2019). Occupational therapists can evaluate and treat clients within each clinical profile based on the OT scope of practice (American Occupational Therapy Association, 2020).
- Studies have shown the most common occupations affected after sustaining a mTBI. Education has been the most researched occupation, followed by activities of daily living, rest, social participation, and instrumental activities of daily living (Sinnett and Franzsen, 2020).
- The physical and cognitive demands of daily activities have been shown to decrease mTBI symptoms, similar to the commonly researched and prescribed aerobic activity implemented by other disciplines (Boisgontier et al., 2020)
Certifications:
Provisional Certified Brain Injury Specialist
- Readings and an associated workbook were completed to study for the certification exam. In upcoming years, clinical hours working with the brain injury population will be submitted to receive full certification.
Certified in Cognitive-Behavioral Therapy for Insomnia (CBT-I)
- CBT-I is an effective evidence-based technique used to help promote sleep in those with insomnia. Sleep disturbances are common in the neurological population, while effective sleep can help promote recovery. Continuing education courses and a certification course were pursued to implement CBT-I in the future.
Educational Materials:
Shadow hours were translated into accurate case studies depicting the management and rehabilitation of acute mTBI and PPCS.
A presentation was created to educate OT practitioners on evidence-based intervention approaches to address symptoms experienced after a mTBI.
A collection of assessment resources were produced to guide clinical reasoning when evaluating clients with a mTBI.
Educational handouts on a variety of topics related to mTBI were created for clients, families, and practitioners to learn more. Handout topics include "The Nocebo Effect and Concussion," "How Schools Can Help After a Concussion," and "How to Know a Bump to the Head is an Emergency."
A flowchart was designed to depict the continuum of concussion care. This resource is intended to help clients, families, and practitioners become better informed about mTBI management.
Additional Efforts
Research
In partnership with my expert mentor and other professionals at CCHMC dedicated to this topic area, we have worked to complete a systematic review pertaining to the effectiveness of occupation-based interventions for pediatric mTBIs. Our intent is to advocate for OT's role in treating this population while educating therapists on evidence-based care. At the time of this writing, editing is underway to submit the manuscript for publication. Check back in for updates!
Future Implications
Impact on OT: Much of my work was bolstered by the research processes associated with a systematic review of OT’s role in mTBI rehabilitation. I hope my completed research, educational resources, and learned expertise may advocate for OT’s role in this area of study while educating others.
Impact on my career: This project has heightened my interest in working with the neurological population. I hope to continue to develop my clinical knowledge and specialize in treating clients with various neurological diagnoses.
Contact: molnarn@huntington.edu
References
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.) American Journal of Occupational Therapy, 74 (Suppl. 2), 74124100101-87.
Boisgontier, M. P., Cheval, B., & Schmidt, J. (2020). Daily life physical activity and concussion symptoms in adolescents. Canadian Journal of Occupational Therapy. Revue Canadienne D'ergotherapie, 87(5), 364–371. https://doi.org/10.1177/0008417420953228
DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged activity restriction after concussion: are we worsening outcomes? Clinical Pediatrics, 55(5), 443–51. https://doi.org/10.1177/0009922815589914
Finn, C. (2019). An occupation-based approach to management of concussion: guidelines for practice. The Open Journal of Occupational Therapy, 7(2). https://doi.org/10.15453/2168-6408.1550
Kontos, A. P., Sufrinko, A., Sandel, N., Emami, K., & Collins, M. W. (2019). Sport-related concussion clinical profiles: clinical characteristics, targeted treatments, and preliminary evidence. Current Sports Medicine Reports, 18(3), 82–92. https://doi.org/10.1249/JSR.0000000000000573
Lumba-Brown, A., Yeates, K. O., Sarmiento, K., Breiding, M. J., Haegerich, T. M., Gioia, G. A., Turner, M., Benzel, E. C., Suskauer, S. J., Giza, C. C., Joseph, M., Broomand, C., Weissman, B., Gordon, W., Wright, D. W., Moser, R. S., McAvoy, K., Ewing-Cobbs, L., Duhaime, A.-C., … Timmons, S. D. (2018). Centers for disease control and prevention guideline on the diagnosis and management of mild traumatic brain injury among children. Jama Pediatrics, 172(11), 182853. https://doi.org/10.1001/jamapediatrics.2018.2853
McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., . . . Vos, P. E. (2017). Consensus statement on concussion in sport— the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 1-10. Retrieved from https://bjsm.bmj.com/content/bjsports/early/2017 /04/26/bjsports-2017-097699.full.pdf
Salisbury, D., Kolessar, M., Callender, L., & Bennett, M. (2017). Concussion knowledge among rehabilitation staff. Baylor University Medical Center Proceedings, 30(1), 33–37. https://doi-org./10.1080/08998280.2017.11929519
Sinnett, F., & Franzsen, D. (2020). Clinical practice in occupational therapy for treatment of concussion in schoolboys: an integrative review. South African Journal of Occupational Therapy, 50(2), 62–69. https://doi.org/10.17159/2310-3833/2020/vol50no2a8
Vargo, M. M., Vargo, K. G., Gunzler, D., & Fox, K. W. (2016). Interdisciplinary rehabilitation referrals in a concussion clinic cohort: an exploratory analysis. Pm & R: The Journal of Injury, Function, and Rehabilitation, 8(3), 241–8. https://doi.org/10.1016/j.pmrj.2015.07.006
Credits:
Created with images by Teeradej - "Doctor demonstrating human brain anatomy and MRI brain on background" • Vitalii Vodolazskyi - "A brain shape from puzzles as a symbol of mental health and memory problems and Alzheimer disease." • Rawf8 - "Teddy bear sick in the hospital" • あんみつ姫 - "作業療法でリハビリする老人"