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Addition of Occupational Therapy to an Interdisciplinary Concussion Clinic Improves Identification of Functional Impairments

Harris, Madison B. OTD, MA, OTR/L; Rafeedie, Samia OTD, MA, OTR/L; McArthur, David PhD, MPH; Babikian, Talin PhD; Snyder, Aliyah PhD; Polster, Douglas PhD; Giza, Christopher C. MD

Section Editor(s): Bazarian, Jeffrey J. MD, MPH

The Journal of Head Trauma Rehabilitation: November/December 2019 - Volume 34 - Issue 6 - p 425–432
doi: 10.1097/HTR.0000000000000544
Original Articles
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Background: Concussions, or mild traumatic brain injuries, are prevalent among youth and young adults. These injuries may disrupt a person's daily activities (occupations) including school, physical activity, work, and socialization. Rehabilitation professionals, such as occupational therapists (OTs), are experts in providing individualized intervention to address these temporary life changes during recovery.

Objective: This article aims to identify the benefit of having an occupational therapy practitioner on an interdisciplinary treatment team when providing intervention to patients with concussion.

Setting: Concussion clinic at an academic institution.

Participants: Participants ages 12 to 24 years with a reported history of mild traumatic brain injury or concussion were evaluated by a physician, or by a physician and OT, in an initial evaluation appointment.

Design: A single researcher (OT) with training in concussion qualitatively compared reported impacted occupational domains as defined in the Occupational Therapy Practice Framework, using both a retrospective and a prospective cohort. The prospective group differed from the retrospective group in that an OT was present, and participated in the initial evaluation.

Results: The domains of performance patterns (P = .007) and performance skills (P ≤ .001) were identified significantly more often when an occupational therapy practitioner participated in the initial evaluation.

Conclusions: Rehabilitation professionals, such as OTs, play an important role in identifying impacted domains after a concussion, which can help optimize patient care.

Steve Tisch BrainSPORT Program and Brain Injury Research Center, University of California, Los Angeles (Drs Harris, McArthur, Babikian, Snyder, Polster, and Giza); Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles (Dr Rafeedie).

Corresponding Author: Madison B. Harris, OTD, MA, OTR/L, University of California, Los Angeles, 300 Stein Plaza, UCLA Neurosurgery, #554Q Wasserman Bldg, Los Angeles, CA 90095 (mbharris@mednet.ucla.edu).

Dr Giza does not believe any of these disclosures represent a direct conflict of interest with the current work; however, in an effort for full transparency, he always elects to disclose all potential conflict of interests. Grants/research support: NCAA, US Department of Defense, UCLA Steve Tisch BrainSPORT program, NIH NINDS (R01 NS27544), UCLA Brain Injury Research Center, Easton Clinic for Brain Health, NINDS Neural Analytics SBIR grant (NS092209 2016-2018). Consultant: NBA, NFL-Neurological Care Program, NHLPA. Advisory panel: Highmark Interactive (2018-2019), MLS, NBA, USSF, NCAA Concussion Committee (end 3/2018). Medico-legal: One or two cases annually. Stock shareholder: Highmark Interactive stock options (2018). Other: Book royalties—Blackwell/Wiley Publishing: Prioritized Neurological Differential Diagnosis.

The authors report no conflicts of interest.

SPORTS-RELATED CONCUSSION is one of the most common injuries reported in youth and young adults in the United States. Between 1.6 million and 3.8 million concussions occur annually, many resulting from youth sports-related activities. According to the Centers for Disease Control and Prevention, a concussion is defined as, “a type of mild traumatic brain injury (mTBI) that is caused by a bump, blow or jolt to the head, or a hit to the body, which causes the head and brain to move rapidly back and forth, creating chemical changes in the neurotransmitters.”1 These chemical disturbances may cause temporary physical, cognitive, emotional, and sleep-related symptoms that can make it difficult for youth to continue to engage in their daily routines. A majority of people will recover from a concussion within 10 days after injury.2 However, about 20% of people experience a prolonged recovery, lasting longer than 10 days, preventing them from engaging in their typical daily routines2,3,13 for weeks, or even months after injury.

After a suspected injury, it is recommended that the person undergo evaluation by a licensed medical professional. Generally, people will see a sideline physician, a primary care doctor, or an emergency department doctor to be evaluated for a concussion.2 Providers utilize tools such as graded symptom checklists, balance assessments, and thorough neurological examinations to diagnose a concussion.4 In some instances, a neuropsychologist is also part of the treatment team, and evaluates cognitive and mood symptoms reported after injury. During recovery, patients are encouraged to gradually return to cognitive and physical activity based on consensus recommendations2 and the majority of them do well.3 However, for those youth who experience a prolonged recovery, they may have difficulty returning to their typical daily activities without individualized care.4

At this point in recovery, it is important for providers to investigate the changes and challenges patients are experiencing in their daily routine. Providers should inquire about difficulties the patient is having with self-care, in school, or in physical activity participation, during social engagement, and in employment, as these are the main “occupations,” or activities, for children, adolescents, and young adults. Discussions surrounding barriers to “returning to previous level of function” should occur, with questions addressing how a patient's identity, routine, roles, daily activities, and other processing functions have been impacted from lingering symptoms after injury.

Rehabilitation professionals, particularly occupational therapists (OTs), emphasize resuming life activities and returning to previous level of function through occupational analyses and occupation-based interventions. OTs use a top-down approach to evaluation in order to analyze a person's ability to perform meaningful activities, such as basic self-care, habits, roles, routines, and higher level life skills. This critical process reveals strengths and limitations in many body systems and performance areas, including strength, vision, and cognitive function to name a few. Interventions include coping strategies, environmental adaptations, activity modifications, education plans, and lifestyle changes to promote successful engagement in meaningful activities during recovery.5 Patients may participate in one session, or multiple reoccurring sessions, to improve engagement in their activities. The focus is on how this temporary “disability” influences people's ability to participate in everyday activities and how occupations (defined above as subject-relevant activities) affect people, given their current strengths and deficits.

This article investigates the need for an occupational therapy practitioner on an interdisciplinary concussion team. Our hypothesis is that the addition of an occupational therapy practitioner will improve identification of impacted areas of daily life that can lead to more comprehensive patient care provided by the treatment team.

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METHODS

Participants

Retrospective data were collected from 51 consecutive patients diagnosed with a concussion or mTBI and seen by a physician without an OT between 2013 and 2015 in an interdisciplinary concussion clinic. Physicians in the study utilized a single electronic medical record template with standardized questions for all 51 patient encounters. However, interviews were conducted in a semistructured way, where physicians had the ability to ask any additional questions they felt were clinically indicated.

Prospective data were collected on 121 consecutive patients seen in the same concussion clinic between 2016 and 2018. For each session, both a physician and an OT were present during the initial evaluation. The OT conducted an occupational profile with each patient alongside the physician's intake interview. An occupational profile “includes information about the [patient's] needs, problems, and concerns about performance in occupations.”7 Questions throughout the occupational profile look to determine why clients are seeking services, what current barriers they may be facing for activity engagement, and what activities are difficult now that patients would like to resume them. The OT also included questions regarding the patients' changes to the daily routine, environmental changes, and changes in identity and role perception (student, athlete, friend, and child). With this information, the OT is then able to analyze occupational performance from the profile to “more specifically identify supports and barriers related to occupational performance and identify target outcomes.”7 The physician in the study used the same electronic medical record template as was used with the retrospective group; however, physicians had the opportunity to ask questions that were not listed on the template to obtain pertinent and clinically relevant information.

The physician referred to throughout the study includes multiple physicians from a single group, all of whom have specialized training in concussion. A single OT served as the researcher for the retrospective chart review for this study, and was present for all prospective initial evaluations included in the study. For each retrospective and prospective case, one OT with experience in concussion catalogued injury characteristics, demographic assessment, and intervention domains from the medical record. The OT was not blinded to the hypotheses of the study and was the sole abstracter for this data set. The OT has extensive training in concussion management in collaboration with a physician.

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Inclusion and exclusion criteria

Patients aged 12 to 24 years with a diagnosis of mTBI or concussion were included in this study. Patients were considered as having a mTBI, or concussion, when diagnosed by the referring physician, documented in the patient referral, and confirmed by the clinic physician. Exclusion criteria included moderate/severe TBI, younger than 8 years or older than 24 years, incomplete patient history, or missing data. If patients visited the clinic on more than one occasion, their follow-up documentation was not reviewed for this study.

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Occupational therapy practice framework

This study was designed using the Occupational Therapy Practice Framework: Domains and Process, 5th edition, a document which, “describes the central concepts that ground occupational therapy practice and builds a common understanding of the basic tenets and vision of the profession.”6 There are 5 key domains OTs assess during an initial evaluation session: occupation (activities of daily living, instrumental activities of daily living, sleep, education, work, play, leisure, and social participation), client factors (body functions, body structures, values, beliefs, and spiritual needs), performance skills (motor and process skills, social interaction), performance patterns (habits, roles, routines), and context (cultural, personal, physical, social, temporal, virtual).7 Although these areas may be addressed in an isolated and unidimensional manner by other professionals including social workers, psychologists, neuropsychologists, and other rehabilitation professions, OTs uniquely address these areas through a holistic lens, grounded in occupational science, within the context of everyday life—which reflects the highest level of ecologic validity. For this study, an OT identified reported impacted domains documented in a physician note (retrospective) or as stated in an in-person initial intake evaluation with a physician (prospective).

The OT identified trends in patient-reported domains, which have been impacted, and developed a tool to use when reviewing patient charts to ensure that there was consistency throughout the data set (see Table 1). A modified version of the Occupational Therapy Practice Framework: Domains and Process categories was used based on typical concussion symptoms in the Symptom Checklist and included part of the Sports Concussion Assessment Tool-57,8 (see Table 1). The domain of occupation was commonly reported as impacted with symptoms such as sleep disturbances, difficulty with attending school or completing schoolwork, removal from sports or all physical activity, or decreased social activities. Reported impact in the client factors domain included patient reports of changes in vision or concerns regarding balance. Negative effects in the performance skills domain included difficulty with concentration, memory, thinking, and attending to conversations. Deficits in performance patterns were recorded when patients reported a change in their daily routine or reported that they felt a loss of identity when removed from enjoyable and meaningful activities. Finally, a child's context domain was impacted when there was a change in the physical location in which the child engages in activity, or experiences changes in socializing with friends.

TABLE 1

TABLE 1

Retrospectively, the researcher looked to identify when a physician documented any impact in activities as listed in Table 1 using phrasing such as “patient is unable to,” “patient is no longer,” “the patient has difficulty with,” and “patient is not.” The researcher then denoted these impacted domains using a tool developed in Excel specifically for data collection purposes, as shown in Appendix A. Prospectively, the researcher documented reported impact in domains as listed in Table 1, within 48 hours of the initial evaluation using the tool in Appendix A. The 2 groups were then compared for this study.

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Statistical analysis

Both the conventional t test and the Yuen test, its robust analogue that controls for outliers in the data distributions, along with Pearson's χ2 test and the Fisher exact test were used to determine significant differences between the retrospective and prospective groups in reported domains. Retrospective and prospective groups were compared for each domain individually, and for overall number of reported impacted domains. All analyses were conducted in R, version 3.5.0.9

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RESULTS

In the retrospective cohort, 51 charts were reviewed by an OT for the study with 2 exclusions, secondary to lack of a completed initial evaluation note. Prospectively, 121 patients were evaluated by a physician and an OT during an in-person evaluation. There were 15 exclusions from this group secondary to patient age or referral, which reported moderate/severe TBI. The OT identified impacted occupational domains reported directly by the patient in response to questions asked by both providers, rather than reported impacted domains documented in a physician note as with the retrospective group. For consistency, data for both cohorts were extracted using the same form (see Table 1) by a single OT (M.B.H.) with experience in concussion management. No blinding was possible although all retrospective and prospective data were collected prior to any analysis to reduce bias. Mean time since injury was 188 days (SD = 328.5) and 274 days (SD 579.6), respectively. There was no significant difference between the 2 groups when looking at time since injury (t test P = .225, Yuen P = .303). Similarly, there was no significant difference when looking at sex between the 2 groups using a χ2 test (P = .122). There was a significant difference reported when looking at the ages of the 2 groups (retrospective mean 16.3, SD 3.5; prospective 19.8, SD 9.0) (t test P < .001); however, this significance was only marginally different in the Yuen test (P = .055) (see Table 2).

TABLE 2

TABLE 2

When an OT assessed the patient during the initial evaluation, more patients reported impacts in the domains of performance skills (P = .008) and performance patterns (P ≤ 0.001) than when seen by a physician alone. An impact in a patient's context was not reported significantly different (P = .058), but this demonstrates that injuries may disrupt a patient's context, which is not recognized and documented by physicians (see Table 3).9

TABLE 3

TABLE 3

Statistics were also determined using a Fisher exact test to identify whether there was a significant difference between the overall numbers of reported domains between the 2 groups. Table 4 shows the number of affected domains in each group. A greater number of affected domains were reported overall (P = .0424) when the physician and the OT conducted a joint evaluation, compared with an evaluation by the physician alone.9

TABLE 4

TABLE 4

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DISCUSSION

According to the data, patients reported 3 to 4 impacted domains during their initial assessment with an OT and a physician, compared with 2 domains documented when only a physician was present. This may occur because physicians may not identify, or document all impacted domains. OTs are trained to identify impact in these domains, which makes them a valuable asset to the treatment team, to ensure patients are receiving intervention in all areas of need to return to their desired occupations and lives. When only a physician is present during the initial evaluation, there is a trend in a higher number of reported impacts in occupation and client factors, and lower reported impact in performance skills, performance patterns, and context/environment. This may be due to the focus on a patient's medical diagnosis and symptoms that are generally reported in the context of daily occupations. With a neurological intake, patients may report, “I had a headache, so I missed school,” so occupation is documented as impacted. However, patients are less likely to explicitly state that, “my routine was changed because of my headache,” or “I am unable to engage in my favorite virtual context because it makes me dizzy.” For this reason, domains may go undocumented and unaddressed by those unfamiliar with the complexity of engaging in daily activities.

Another factor to consider is that all patients included in this study were seen in a specialty concussion clinic. Providers in specialty clinics generally have more time with patients than someone who is working in a primary care office or an emergency department. It is possible that the providers in specialty clinics are able to better capture the impacted domains, because providers have more time to explore a patient's daily life than those working in other settings. This would mean that a patient's change in meaningful occupations may be underidentified in clinics that do not have an occupational therapy practitioner on their interdisciplinary team. The results of a study conducted in a pediatrician's office may demonstrate an even greater magnitude of OT effect than in a specialty clinic. There are a variety of intervention approaches that an occupational therapy practitioner may implement when working with patients who are recovering from concussions.

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Benefit of including an occupational therapist in an interdisciplinary clinic

Earlier concussion management recommendations emphasized the importance of rest after a concussion. Patients were advised to refrain from all activity until symptoms resolved.10 This included removal from school, social situations, and physical activity. In other words, youth were removed from all of their meaningful occupations. Recently, studies have shown that “complete rest” may actually prolong postconcussive symptoms, making recovery challenging.11 Research is now showing that youth who have had a concussion should rest for 1 to 2 days after their injury and then slowly return to their typical daily activity with accommodations in place.12 Occupational therapy practitioners can work with patients to develop therapeutic strategies and activity modifications to minimize change in routine during a gradual return to play/learn program.13 If patients are continuing to experience ongoing symptoms, providers can use behavior changes and lifestyle factors to help manage the intensity and frequency of stress or pain in collaboration with any medications the physicians may prescribe.14

Although this article specifically looks to identify the role of an occupational therapy practitioner in a concussion clinic, it is understood that not all clinics will have access to this healthcare provider. However, it can be stated that patients who experience a concussion may benefit from an occupational therapy practitioner on an interdisciplinary team, especially during prolonged recovery. Rehabilitation professionals such as speech-language pathologists, physical therapists, social workers, and psychologists can address many of the reported “symptoms” that are listed in Table 1. Having multiple providers, including OTs, working with a patient will allow for domains of occupation to effectively be addressed through unique strategies and skills that may improve patient outcomes.

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Future directions

Occupational therapists are driven to understand the complexities of people's choice in how they live their lives and balance activities that include work, rest, leisure and play.15,16 According to Yerxa, it is equally important to understanding humans as, “occupational beings who have the need for, and the capacity to engage and orchestrate daily occupations”5 over the lifespan. Currently, there is limited research identifying the need for an occupational therapy practitioner's role in a concussion clinic. This article, as well as future studies that develop from these results, will help to set the foundation for inclusion of occupational therapy practitioners on the interdisciplinary team in the realm of concussion treatment.

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Limitations

There are several limitations to this study. One limitation may be that a single researcher performed both the retrospective and prospective data collection, which may result in possible bias. With a single researcher, there is no concern for interobserver bias as there would be if multiple individuals scored the encounters. Second, the occupational therapy practitioner and the physician worked in collaboration for the prospective portion of this study. As time progressed, the physician may have learned the occupational domains that the occupational therapy practitioner was looking to identify and could have started to identify these domains independently. In such a case, however, the addition of the OT in the clinic remains a benefit to the patients by facilitating better identification of impacted domains and development of more comprehensive treatment plans that are client-centered and occupation-based. Although there was an age difference noted between the retrospective and prospective groups, we do not believe that this would have a significant impact on reported domains. Another limitation to this study may be the particular population in which this clinic serves. A majority of the patients are referred to this concussion clinic because they have not demonstrated improvements while working with their community providers. For this reason, many of the patients seen in this clinic may be several months postinjury, and may have been removed from activity for the entirety of this recovery time. This patient presentation may be unique to specialized concussion clinics and may not be as generalizable to the typical concussion population.

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CONCLUSION

This study demonstrates that a greater number of impacted domains were identified and reported when an OT completed an assessment during a joint evaluation of chronic patients recovering from traumatic brain injury, rather than when assessed by a physician alone. Occupational therapy practitioners can provide a unique contribution to the plan of care, with a variety of evidence-based interventions and occupation-based domains that are beneficial to this patient population. There is a benefit to having an interdisciplinary treatment team focused on supporting youth back into their meaningful activities. The patient, family, and treatment team can collaborate in implementing client-centered remedial or compensatory strategies and skills to resume everyday activities, as well as managing physical, emotional, cognitive, and sleep symptoms to meet their individualized goals.

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REFERENCES

1. Center for Disease Control and Prevention. What is a concussion? https://www.cdc.gov/headsup/basics/concussion_whatis.html. Published 2017. Accessed January 21, 2019.
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9. R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2018. http://www.r-project.org.
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12. Brayton-Chung A, Finch N, Keilty KD. Back in action: the role of occupational therapy in concussion rehabilitation. Am J Occup Ther. 2016;21(21):8–12.
13. Cooksley R, Maguire E, Lannin NA, et al Persistent symptoms and activity changes three months after mild traumatic brain injury. Aust Occup Ther J. 2018;65(3):168–175. doi:10.1111/1440-1630.12457.
14. Sahai-Srivastava S, Sigman E, Uyeshiro Simon A, Cleary L, Ginoza L. Interdisciplinary team treatment approaches to chronic daily headaches. Headache. 2017;57(9):1482–1491. doi:10.1111/head.13118.
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16. Clark FA, Parham D, Carlson ME, et al Occupational science: academic innovation in the service of occupational therapy's future. Am J Occup Ther. 1991;45(4):300–310.
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APPENDIX A

Table

Table

Keywords:

concussion; neurology; occupational therapy; pediatrics; quality of life; therapy

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