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Episode
Kate Grandbois: Hello everyone. Welcome Nas LP Nerd Cast. We are here today with three special guests. Uh, this is a topic that Amy and I have not really worked with a lot personally, but we have talked about it a little bit on the podcast. Before today's gonna be a [00:02:00] deeper dive and a little bit of a different spin, uh, we are very excited to welcome Laura Wilson, Rachel Hildebrand, and Jennifer Stewart.
Welcome, Laura. Rachel and Jennifer. Hi. Thank you for having, having us. Hi. We're so glad that you're here. We would love to learn a little bit, um, about you. Before we get into all of the good stuff, do you wanna, uh, tell our audience a little bit about each of you?
Laura Wilson: Sure. Rachel, you wanna go first?
Rachel Hildebrand: Sure, I'll go first.
Um, my name is Rachel Hildebrand. I am an athletic trainer, um, for many years more than I'd like to, um, state and, um. I don't know, Laura, like 10 years we've kind of been in the concussion space together. Um, I always joke with her that like right before we got into it, I was at a national convention and I was like, if I never talk about concussions again, um, it'll be too soon.
And then I, so I always tell the, like, our students that we work with, like, hey, like never say things like that because you never know where [00:03:00] you're gonna end up. But we've been working, um, in this space for about 10 years together, um, interdisciplinary. And then, um, about five years ago, uh, brought Jennifer on and so the three of us have been really diving into concussions and like, and how to manage interdisciplinary.
So that's me.
Laura Wilson: Um, Laura Wilson. I'm a speech language pathologist, and I started my career focused more on severe traumatic brain injury, but over time have evolved into this concussion, mild traumatic brain injury space. I would say, um, really having this opportunity to work in an interdisciplinary, uh, manner with my colleagues who are here today has been, uh, probably one of the most fun and rewarding, uh, parts of working in this space.
So we're really glad to be able to kind of share that, uh, today. So yeah, I've been working in concussion for about 10 years now.
Jennifer Steward: And I'm Jennifer Stewart. I'm a clinical psychologist and I kind of had an interesting way to come into this. My, my [00:04:00] role within our university is a, I run our training clinic for our clinical psychology students and, um, we happen to have a, a graduate student who was really interested in sports psychology and concussions.
And, um, he was the one that was initially like, introduced to Laura and Rachel to kind of help give the concussion center up and running. And, um, I, I just kinda came along with him as being the licensed person, uh, along for the ride. And so I had done some. Work over the years with, um, training in neuropsychology settings and other kinds of, uh, interdisciplinary teams, some chronic pain, uh, interdisciplinary work.
And, um, it happened to be a really great fit. And similar to what Laura was saying, I, it's been some of the most fun clinical and interdisciplinary work that I've ever, I've ever done. So, uh, I've been really excited these last couple years to, uh, get the center off the ground and to be doing some really cool things in our community.
Kate Grandbois: I'm so excited to learn more about [00:05:00] this. I feel like this is a, we've talked about this on the podcast before, just the power of interdisciplinary multidisciplinary work. How the people that we serve are impacted in so many ways, just beyond communication disorders. Um, and I am very much looking forward to seeing how this, um, this conversation unfolds and, and how we can as professionals more deeply embrace the idea of interdisciplinary care for this population.
I think this is gonna be really exciting. I do need to read our learning objectives before we get started. Um, so participants who take this course will be able to self-report knowledge gains related to the importance of the SLP role in concussion management.
They will also be able to report knowledge gains related to best practices for interdisciplinary management of clients with acute and persistent post-concussive symptoms, as well as report knowledge gains related to the process for development of a concussion center. [00:06:00] Uh, any and all financial and non-financial disclosures for all of the presenters on today's episode are listed in the show notes as well as on our marketing materials and the course webpage.
You can get to the course webpage to read all of this information and take the post-test for Asha CEUs, uh, through the show notes, um, as well as you know, YouTube description and on our website. Okay. That's the boring stuff we're it's already done. That's so great. Um, I would love to hear a little bit about what, where do we begin with concussion management?
Where would you all like to start this discussion?
Laura Wilson: Yeah, I think. Uh, Jennifer and Rachel don't mind. I'd like to start by thinking about the SLP kind of role and how that plays in and how I've thought about how that role has evolved based on what I've learned from them, and then, um, pass it to them from there. Um, I would say [00:07:00] that although it's been quite a while now, that speech pathologists are in this space, uh, it's still for many of us, uh, a space that we're not super comfortable.
In perhaps as a field. And there have been some studies really in recent years from some of the heavy hitters in the concussion speech path world, um, that show that really primary care physicians, um, other medical providers are still not very good about recognizing the role of speech path and referring to speech pathologists as as necessary.
Um, so I think that one of my goals when I've gone had the opportunity to go and talk in more of Rachel's spaces and in the athletic training world is to really just kind of highlight the, uh, potential benefits of including speech pathologists in, in the management. Um, so when I think about that, I think about our.
Training in terms of, uh, cognitive communication, right? So we have training that helps support things like, uh, attention and executive [00:08:00] function skills that can be impacted by concussion. But we also have a lot of training related to things just like accommodations in the schools, right? So we are really good at thinking about like, hey, functionally, what are the challenges and how can we adapt the environment to help people be successful?
And that's a really important thing, both acutely post-concussion and in, in the folks who take a little bit longer to recover, um, as well. So I think again, that sort of accommodation space and then the more traditional cognitive communication rehab space is really important. Um, and then I think another role that we have is around, uh, education.
Um, and that's not unique to speech language pathologists. All of us, uh, have that role. Um, but there's been a lot of work to show that the way in which we talk to folks about concussion. When they present to us early on, um, impacts how long it takes them to recover. So the words we choose, the way we talk about it, the way we frame our expectations, the way we understand their goals, um, [00:09:00] regardless of what else happens in therapy, can dictate to some degree how well their recovery is gonna go.
So I think that education role is, um, is really important.
Rachel Hildebrand: I'll just add to that, um, specifically in the role of the speech pathologist, Laura and I do a lot of, um, dual task therapy together. So, um, I might, and we kind of base it on who takes the lead based on whatever goal our particular patient needs to work on.
Um, but I might have them do a physical activity and Laura's just throwing cognitive, um. Strain at them. So I've learned a lot from her. I now, now I'm like, Hey, I can do that. Um, I can't, um, not near as good as she can, um, or other speech pathologists at the clinic. Um, but I think that that's a big way that the interdisciplinary aspect of the concussion clinic or concussion management comes together as well.
Um, is, is really [00:10:00] playing off of each other's strengths and trying to dual treat as much as possible for the, the individual patient.
Laura Wilson: I think too, in the same way we would do in a more sort of like traditional rehab setting where, uh, PT may be working on transfers, for example, that a speech language pathologist may be working on sort of like sequencing and, and environmental accommodations to support them being able to engage in that transfer.
I think we have a lot of conversations as a team, and I think that's an important role of the speech path as well. Um, to say like, Hey, we're having trouble, uh, because they're not doing these homework exercises at home. And so we can say, okay, well, like, is it a, is it a memory concern? Do they not understand it?
Is it a sequencing? Like what is the challenge there? What is the barrier? Um, and those barriers could be cognitive communication in nature. They could be psychological in nature. You know, there, there are many reasons. So kind of troubleshooting, um, can, can be an important role, uh, as well.
Amy Wonkka: As we're talking about this, I'm trying to conceptualize [00:11:00] what your C clinic looks like and who, who is coming there? So, you know, when before we started recording, we were talking about how, you know, when I was in grad school, I did like a placement at a subacute rehab.
I'm assuming those aren't your clients. Who are you seeing? Are you seeing mostly like adolescents? Are you seeing sports related? Um, kind of who's your population there? If you could help us just better understand that a little.
Laura Wilson: It's not what we, what we thought it was going to be. Um, I would say I think we anticipated a lot of sports related concussions.
Um, that is, uh. In large part due to Rachel's connections in the community that she's built over many, many years, we, you know, we are well connected in the sports related concussion community. Uh, but I think what we've come to find is that a lot of the sports. Related concussions that occur, occur among people who are embedded in a system that already has support for them.
And so as long as they're having [00:12:00] kind of a typical recovery, um, they are, are getting services to some degree and may not need, uh, an interdisciplinary clinic that specializes in concussion like ours. Um, now we do see those folks with sports related concussion who may have slightly more complicated recoveries, um, who may not be kind of responding to standard of care.
Um, but we have seen a lot of individuals with motor vehicle, uh, uh, post-motor vehicle accidents. Um, and what we've kind of come to learn is a lot of these folks are not embedded in communities or systems that offer support. Uh, and so they're not getting the care that they need either, like, like right away.
And so often, uh, that can prolong recovery. Um, or they're coming to us pretty quickly because they, you know, need to get back to work and have this concussion and, and are trying to figure out what's going on. So. Some falls, uh, you know, if we think about the main causes of concussion, so, and we're, we use concussion interchangeably with mild traumatic brain injury, right?
So common causes would be falls, motor vehicle accidents, sports [00:13:00] related concussions, um, uh, interpersonal violence, uh, and another cause. And we, um, we see, we see patients who have concussions as a result of that as well, but, uh, much heavier on the motor vehicle accidents than I think we anticipated, uh, going into things.
Amy Wonkka: That's really interesting. I mean, that, that makes sense, right? Because we are a nation of cars and there are so many people driving around and we have a lot of motor vehicle accidents. Um, so yeah, that, that does make sense. But that's interesting. That wasn't what I was picturing, so I'm glad I asked that question.
Yeah. Um, with your varied clientele, does that mean that you're finding yourselves interfacing with different agencies, right? Like, are you working with people who are still attending schools or are you coordinating with their primary care or other, other agencies out there? And what sort of, what does that look like?
Rachel Hildebrand: Yeah, so, um, we do a, a lot of, um, release of information, [00:14:00] um, for that reason. So it we're coordinating with primary care a lot, um, or, um, and I, Jennifer could speak more to this, but we might discover that. Uh, through their injury, they have, you know, um, more intense like mental health, uh, dealings that they need to help with.
So, you know, coordinating with long-term care that way. I mean, we're set up to be pretty short-term care. Um, and so, uh, primary care, um, we do a lot with neuropsychologists, so we've already hand out to neuropsych, um, working with if they are a younger athlete, um, working with an athletic trainer or coordinating with parents, uh, trying to coordinate with the schools, um, and stuff like that.
So yeah, we do a lot of coordinating care through our center as well.
Laura Wilson: I think maybe it would be helpful to, uh, if it's alright to kind of talk about how our clinic is structured and, and, [00:15:00] and what that looks like to kind of set that framework. So, um, like Rachel said, we're uh, set up to be short-term care, so we will see anyone, um, who.
Has had a concussion. We don't see people same day, uh, but as long as it's at least the next day post their injury. Um, and they don't have to have a diagnosis of a concussion, uh, of an acute concussion, um, that falls within the scope of practice for Rachel. Um, and then we see people up to, we typically cap at about two years post-concussion.
And, and we can get into more about why that is, if, if that's helpful. Um, but so we, we see a pretty big variety of time post-injury. Um, and then for our individuals who are more acute, our kind of expectation is that we would, we would kind of plan for about four weeks. Um, and some people don't need that long, right?
Some people are kind of back into their baseline, back at their, you know, normal desired life activities sooner than that. Um, but we plan for about four weeks for people who are, uh. [00:16:00] Further out post-concussion. Um, so suggesting that they have perhaps some risk factors that have predisposed them to taking a longer time to recover.
Um, then we'll expect to see people for about eight-ish weeks. Um, and then we reevaluate and if people need to be seen, uh, longer and are, um, still kind of a good fit for the center, then we can continue to see them as well. Uh, but we're not, uh, really set up to see people for, you know, years at a time. Um, and for most people with concussion, that's not an appropriate, uh, care plan anyway.
So for the most part, we're getting people in, getting 'em the services that they need. And then, um, you know, hopefully getting people back to where they want to be kind of functionally and quality of lifewise. And, um, if not, then we often are gonna kind of refer out to other community resources.
Kate Grandbois: I wanna comment on something that struck me about what you, what you said a few minutes ago related to people who are dealing [00:17:00] with a mild traumatic brain injury concussion, uh, regardless of how far out they are from the incident of injury, that they tend to lack a community.
Something about that really kind of stood out to me. Um, and then Rachel, you mentioned that there may also be some mental health components and I, I can't help but feel like people who have experienced this, this trauma, this head trauma of whatever source, motor vehicle accident sporting event. You also mentioned interpersonal violence.
Um, I have to imagine that. There are components of community, there are components of interconnectedness that come along with that interdisciplinary care, that are critical for the, for healing in this population or for recovery. Can you tell us a little bit about that aspect of community and, and community support and how your interdisciplinary team works to [00:18:00] strengthen that community?
Jennifer Steward: I, I think one of the biggest things is access to care. We, one thing we've learned is that, you know, what people are getting told if they present to like their primary care or to an ER, is they're, they're getting told a number of different things in terms of what they should and shouldn't be doing immediately post-concussion, um, and what they should expect in terms of trajectory of, of their recovery.
And so when we see someone who's been, you know, 6, 9, 12 months post-injury even out to, to two years, and they, they're still struggling with many of those things. They, they see their injury as the precipitant of all these things that have been going on for them. And they're, they're presenting to their usual care team with no real results.
Um, like it, it hasn't followed that trajectory. The, the, the doctor is telling them, well, there's nothing that I can do. You should have recovered by now. Um, it leaves them in a really frustrated place. It leaves them in a place where they. They [00:19:00] don't feel believed, um, or where they don't feel heard. And so being able to at least give them a different perspective of, of like, our intakes are interdisciplinary when a, a new patient comes into the, the center.
Um, so we've got all three disciplines typically represented at each of the intakes. And so we're all three listening to different pieces of that and trying to understand like what role each of our disciplines could take in that, that care that would follow. And so, um, being able to just offer options, offer things that might be, you know, take a different approach than what they've received before.
And so oftentimes that, that, that's one of the biggest things for our, our. Clients who have a more prolonged presentation is just that feeling of being heard, right? Like, if they've just gone to their typical care and they're not feeling like they're heard now they're getting, you know, a, a space where they have three different disciplines and they, who they probably haven't worked with before.
Um, and, and they're listening to their concerns in a very different [00:20:00] way and able to come up with a plan to hopefully make some, some movement there. And so I think giving that, that hope is a big piece of it. Obviously, like some things might, you know, we might need to work on from the acceptance angle of like, maybe there are some things that aren't going to quite go back to the way they are.
They were, maybe that's injury related. Maybe that's normal aging related. Um, but it, it's something that we can at least give them a different perspective to work from.
Amy Wonkka: You mentioned, oh, sorry. Go ahead, Rachel.
Rachel Hildebrand: No, I was just gonna say, I, I was just gonna follow up. I, I do think one of the coolest things about our clinic is so many times we will have people come that have gone to primary cares or, you know, gone to various healthcare providers.
And it's not saying anything about healthcare providers. We're just specifically trained in concussion and concussion management. And we're able to be like, yes, what you're experiencing is real. Like, we've seen it, we deal with it every day. And just kind of the, you can almost see the sigh of relief [00:21:00] come off of, um, our patients is, they're like, okay, like somebody hears me and understands.
And I think that just that, um, goes a long way to healing of saying like, yes, like this is a real thing. Um, and, and through our ability to approach it in three different directions, um. I, I like a lot of it is just, uh, like being said, like, yes, we validate you, like we hear you and, and what you're experiencing is real.
So, you know, I, I think that that's a big aspect toward the recovery in, in this way.
Laura Wilson: I think something that's challenging is that, um, the best practices for concussion care have changed pretty dramatically in the last 20 years. So I can reflect back to, um, a sports related concussion, uh, that I sustained, uh, you know, in high school and at the time, uh, you know, everyone got a CT scan of some kind if they [00:22:00] had access to it, right?
If you went to the er, that was like common practice. They told you, um, that you needed to be, um, checked on every 30 minutes. So you were, you know, they have someone wake you up constantly. To make sure you're doing all, all right. Um, essentially you were told that you needed to like, rest in a dark room until your symptoms had gone away.
And all of these things that we know are, are actually not best practice. So there are specific guidelines now for, for example, who should get a CT scan if they present post, uh, concussion. And frankly, it's not, uh, necessary or helpful for most people. Um, two, we don't wake people up all the time anymore.
Rest is really important. Um, and three, uh, there's, there's pretty clear evidence now that prolonged rest periods actually make recovery harder and that we should do this. The management that is really based around, and I think Rachel's done a really good job of reinforcing this in our clinic, this idea of, um, symptom exposure and then recovery, right?
So you engage in activities, [00:23:00] you don't wanna major symptoms spike, but you know your symptoms will elevate a little bit when you engage in physical and cognitive work. Post concuss. As long as they just elevate a little bit, then you do that work and then you step back and you recover and then you do it again.
And you know, this sort of active recovery process is really important. And so when I think about, um, when we see clients now who perhaps are my age, um, and we're kind of raised in a much different kind of practice environment, uh, they, you know, thought about it as getting their bell rung as a kid or, you know, maybe they were told to toughen up or whatever.
And so when the, a concussion happens and people don't get better, so to speak, right away, they think something has gone sort of terribly wrong. Additionally, um, uh, and again, not trying to, um, knock other providers, but, uh, if you think about primary care physicians, they have to, you know, they have to manage like everything.
And so, [00:24:00] um, we do see some situations where. People are not up to date, uh, in terms of best practice recommendations. So they come to us, um, you know, uh, a month for example, uh, after their concussion. And they have not like returned to school or work in any, in any, uh, like in any way at that point. 'cause they're like, no, I'm waiting for my symptoms to go away.
Okay, what are you doing with your day? I'm just hanging out at home waiting to feel better. Like, oh, okay. Uh, you know, so we, we, uh, and we unfortunately see that like those folks are gonna take longer to recover. So we're, we're navigating some like changes that have happened more recently in best practices.
Some like stigma and misperceptions on, on, uh, on uh, the part of the, the patients. Um, and so, yeah, I think that sort of hearing, listening, validating, educating piece, um, goes a long way. We've had, um. Folks who were essentially told like, you'll be back at baseline in two weeks. I'm like, [00:25:00] just straight up, you'll be fine.
And so then if, you know, if your doctor tells you that and then you're not fine in two weeks, you feel like something is wrong. Um, and we've had actually more than one occasion in which, uh, someone was very concerned that they had dementia, um, because they're like, it's been three weeks. They said it would be two weeks.
I have this family history. You know, like, I'm, I like, like what is the rest of my life gonna look like? Well, let's, let's slow down a little bit and kind of, kind of talk through that. So it's, it's, yeah, a lot of education and, um, that's, you know, uh, Rachel heads up our community outreach and that's, you know, that's part of our mission too is to, um, to try to get the word out directly to, you know, um, just general people in the population, but also to providers to make sure that we can all get on the same page about, um, about how to manage this and what that, that message should be.
Kate Grandbois: I wanna quickly just reflect some of this back to you and, and connect it to your first point about the role [00:26:00] of the SLP. So everything from making sure that a, a person feels heard and the power of feeling heard, feeling validated, um, especially when you're maybe getting misinformation or you've been wrongly diagnosed, or you have the, the comment, had my bell rung evoked some sort of like 1930s guy on a railroad.
You know, like you, you have all of these cultural misconceptions or, uh, bad information in the community and the power of feeling heard and the power of being validated. Thinking about the SLPs who are listening to this, who, you know, we don't necessarily get direct care and counseling as speech pathologists.
Um. A lot of us do have teams, but maybe the relationships that we have with the school counselor or the relationships we have with the other mental health professionals in our field could be strengthened or better utilized or better brought in just because of the [00:27:00] power of that, um, that, that phenomenon of, of being heard and, and being validated in the face of the misconceptions and the, you know, the bad information.
Um, do you all feel like. It's a, I mean, I guess this is kind of a rhetorical question 'cause of course you do, but do you agree that speech pathologists should be, you know, making better relationships with their psychologists, their school counselors, or being, you know, more open to embracing components of counseling, taking courses in counseling?
It's just, we talk about this on the podcast all the time. It is such an important piece of every single thing that we do, uh, in speech pathology. And yet it is an often not the central focus of our, our jobs. I dunno, commentary question. Please gimme feedback. May perhaps take you take that off for too long.
Rachel Hildebrand: Um, I, no, I totally [00:28:00] agree with you, but I, I think that's, um, healthcare in general, right? Um, I've recently consulted with some of our local high schools and on, on and from the athletic training standpoint of their concussion management. And I'll look at it and I'll like, good, who's your speech pathologist at your school?
And they're like, we don't know. I'm like, who's your, who's your mental health, um, provider at your school? We don't know. You know? And I'm like, no. Like, those are the people you need to go talk to. So I'm gonna not throw the SLPs under the bus and say that it's on SLP to make that connection. I think it's a general, um.
Overall in healthcare, we need to be making that connection. And, um, because we do, we have so much to learn. It's just like the primary care physicians. And we'll tell our patients all the time, like, 'cause they'll be like, well, why didn't my PCP tell me this? And we're like, because they have to know every other system of the body, right?
Like, we get to talk about the brain, um, and the brain alone. And so I, [00:29:00] I think it's, um, incumbent upon healthcare as a whole to get out there, right? And kind of get out of our own own bubbles and be able to figure out where we can collaborate and where we overlap. Um. I mean, in my own profession, we were talking about standards for education the other day, and we had people like, we need to do more about like this and that.
And I'm sitting there going, no, like literally, I was like, no, we need to just talk to the SLPs. What are we doing? Um, focal cord dysfunction. That was one of 'em. And I was like, we don't need know about that. We need to know. Send it to an SLP. Um, so I, I do think that there's an element that yes, I mean, the answer to your question is yes, like LPs need to get out there, but I think every healthcare professional needs to get out there.
Now, Laura can pick it up.
Laura Wilson: I think one of the things that came to mind with your, uh, your question about kind of counseling and, and that role in that training, um, we also are a teaching clinic. So, [00:30:00] uh, we supervise, uh, graduate students in the clinic. And I would say that, uh. Of, you know, our students go out and work in lots of settings, but I think that the concussion center has, uh, been a little bit nerve wracking for a lot of them because a lot of it is counseling and a lot of it is responsive.
We see, especially in more acute concussions, we see pretty quick changes and so unlike perhaps some of our other patients where you could plan a week in advance what your session is going to look like in these sessions, we essentially. Go in, you know, we kind of reflect on the goals that we've set together as a team with the patient.
And then we say, okay, so this was your goal. How has that been going the last couple of days? And sometimes I'll say like, actually that's, that's been totally fine, but this issue has really been a challenge. And then we have to be ready to sort of pivot and educate and problem solve in the moment while building in that, um, those [00:31:00] counseling skills to help build insight and help the client think about their role and their, you know, their own role and their recovery and that kind of thing.
So it's, um, I think one of the things that makes it fun to me, uh, to work with this population is that it's, um, you never quite know what's gonna happen when you walk in the room. Um, I think that is also something that makes it a little bit intimidating and, um, a little bit of a, a hard entry for, uh, clinicians who are newer to this area.
So.
Rachel Hildebrand: I will throw Laura under the bus a little bit though. Um, when we first started this clinic, she'd come up to me and she'd be like, because the athletic trainer, that's, you know what we do, we're always on our feet. She's like, so what are you doing? I was like, I don't know. When I see 'em, I'll figure it out.
And um, even our, our psych students sometimes they'll be like, what do you mean you're figuring it out in the room? I was like, I don't know. That's what we do. Like, so, um, it is been fun to watch. Um, our students, um, also adapt to that [00:32:00] and figure that out and navigate that.
Jennifer Steward: Yeah. That, I think that's been one of the most interesting things about working as part of this interdisciplinary team is like. Everyone's approach to how we set and measure goals. What are we doing in terms of, of prep? So our, we, we staff, um, all of our, our patients every week. And so that's, that's often like a, a funny like, comedic point actually.
It's, it's kind of turned into like a comedy bit, um, to where like, Laura's on the side of like, but what's the goal? And Rachel's on like, I don't know, we're gonna figure it out. And so it's been a, an interesting, and then Psych is kind of in the middle of, we like, well, okay, we'll just kind of hold both at the same time and like see where it goes.
And, um, but yeah, Rachel mentioned the stuff with, with training. I think that's also been a really interesting piece because how the role that our trainees play within the, the center has also played a, an interesting role. And so, um, you know, I'll start with with our psychology ones are. Psychology doctoral students are in their third or fourth year of training.
Um, we've been lucky to have some [00:33:00] people who, you know, they, they're, they're on a placement for, for typically a full year, if not mean, really everybody's stayed for, for two years, um, which is really exciting. They've, they've loved the work that much, and so they are, are, are part of the team. They are an active part of the staffing.
They are contributing, they're creating their care plans. Um, I'm not in the room. I just watch things over video and, um, and have fun, fun doing that. And so they are kind of treated as like. Many providers, they're like, their, their, uh, voice, their opinion is, is what's guiding that. Their, uh, observations, they're doing the intakes, all of those fun things.
Whereas on Rachel's side, like she has, you know, her students rotate with her two weeks and then they're onto the next, uh, next placement. And so the role of the student within that is, is very different for each of the disciplines. And so it's been a really good opportunity to kind of see how each of our disciplines approaches clinical training [00:34:00] and what, um, how that looks different within this, this particular setting.
Amy Wonkka: There are so many benefits to an interdisciplinary collaborative setup like you guys are talking about, I mean, from the actual training and content skills that people bring, but also like you're mentioning just the differences in training and approach and being flexible and working within that. Um, Jennifer, earlier you mentioned just your interdisciplinary assessments, and I was wondering if you guys could talk to us a little bit about the different pieces that you are bringing to that assessment process and what that might look like.
And then I guess also if there's a difference between what your assessment process looks like for somebody who you're seeing in that acute phase versus somebody who you're seeing who's maybe one of those more chronic patients,
Laura Wilson: more That's been something that we have, um, been refining. Let's see, the, the center's been open for about two and a half years now. Um, and that's been one of our. [00:35:00] Goals for the last six months or so was to really, um, have a more standardized practice for, based on sort of the stage someone is at in their recovery.
Um, and uh, I think when we first started, uh, it was largely Rachel and I and one of the initial, um, clinical doctoral students, uh, psychology and doctoral students. And so we were able to be a little bit more flexible. We could staff things like sort of chat about things a little bit easier. And then as it grew and we had more patients and then um, like a big influx of student trainees who were going through and that kind of thing, we just realized that we needed to sort of like have that nailed down a little bit.
So Rachel actually spent, um, quite a bit of time. Finalizing those protocols. So maybe you'll talk about those, but I wanna just kind of highlight that. It was definitely an evolution. Um, so I think that sometimes, uh, I know when we were first starting out, we kind of looked to some other centers that existed and it just frankly felt a little bit overwhelming.
They had all these, all [00:36:00] these protocols that it seemed to be all so clear cut. Um, but so I just wanted to to mention that like, that has, that has evolved and I think we're pretty happy with where it's at right now, but we're, we're tweaking it constantly. Um, and we definitely didn't just sort of hit the ground running with those protocols.
We felt it out and learned from it and, and that kind of thing too. But yeah. Rachel, maybe you can talk about the, the, um, the current protocols for the different stages.
Rachel Hildebrand: Yeah. So I think we're, we're down to now just two protocols. We started with. As Laura said, we were just kind of all over the place. And then we went to three protocols with like this subacute phase, and then we, we realized like acute and more prolonged down to kind of those two phases.
Um, with our acute, uh, it's, so our, our intake, um, as Jennifer mentioned, we have all three professions in the room at the same time. And the reason we do this is, um, well, several reasons that we do that. But, but one, I mean, you're talking to people [00:37:00] with, uh, brain injuries, so you don't wanna just keep asking them the same questions over and over again.
So one, it allows us to be more efficient. Um, two, Laura might ask a question and they answer it in a way that makes me go, oh, wait a minute. Now I have a question based on your answer. So it allows us to, um. Not only ask the same questions over and over again, but allows us to kind of hear the same information from three different points of view.
Um, which allows us to then whenever we do our, our rounds, um, on the patient, uh, then we're able to like, but they said this, so I heard this and you know, I kind of heard this, and so, oh, maybe we need a dual task here, or we need to, you know, do something here. Um, and so that allows, uh, just like a little more efficiency I think for our patients.
The other thing that a lot of people will come in and they'll feel fine when they start, and [00:38:00] then with all three of us in there, again from different points of view, you can almost just watch their cognitive decline happen. Um. And so as we're we're talking to them, it allows us to visually see how sitting in a room, how having to cognitively think or emotional ability, um, you know, and kind of how their emotions go up and down.
Um, all, all play into that. So again, it allows us efficiency, better patient care, but then also to like visually see what's happening instead of Laura's in the room first and she's like, they're great. What are they talking about? And Jennifer's students in the room last and they're like, they were terrible.
They couldn't talk to me. Right? So we have everybody come in. Um, we, every day we do a symptom checklist. Um, we do, uh. Cognitive, can
Laura Wilson: I pop in real quick? Yeah. Because I don't know what, what the audience right. Some, so in speech path, like there's definitely, oh, sorry. So no, you're so symptom checklist. It's, uh, kinda the [00:39:00] standard ones are like 22 questions and you just rate it on a scale of like, zero is, I don't have that.
Symptom six would be it's very severe and you just get a total score. It's things like, um, do I feel mentally foggy, any dizziness, any headache, trouble falling asleep? Um, and it sort of like mood related question. So it just kind of covers those areas that we see sleep trouble, cognitive trouble, physical trouble, uh, psychological trouble essentially.
Um, it covers, uh, those kind of main points. So it's just, it's a, a really common way that we kind of track. Uh, subjective recovery essentially.
Rachel Hildebrand: Yeah. And so then with that, um, and then we'll, we'll have an interview. So like, just basically what happened, what symptoms did you feel initially, how, depending on when they came, how long it's been since their injury, like how have those changed now?
What makes 'em worse? What makes it better? Kind of a standard intake interview. Um, then we'll do trail making, test B and verbal fluency from the cognitive standpoint. [00:40:00] Um, and then as Laura mentioned, with the symptom checklist, we're able to, um, break it out into those four domains. So they might be telling us, um, I don't have any trouble with, uh, or all my, you know, they might be telling us in the interview like, I'm emotional and all these types of things, but then in their symptom checklist, like it's all cognitive that they're reporting.
So it kind of allows us to, to, again, when we talk about a care plan, be like, well, they weren't. Acting like this, or they didn't tell us this is a problem. So maybe it's not like consciously a problem, but it's subconsciously a problem in some way. Um, so, and that's kind of where we're able to look at like dual tasking, uh, where that comes in.
Then everybody comes back for a full physical assessment. We used to try to do the physical as a part of it. I think our intakes were about two hours long. Um, it was visual for, it was no good. It was visual for them. Um, so we kind of, we parsed in the physical testing out of that, which is a lot of balanced testing, um, looking at [00:41:00] orthostatic, uh, changes and, and, uh, but concussion treadmill test and stuff like that.
Then we, um, if, if we've just, um, had our weekly meeting, then we might. Round on them earlier, but then in our weekly meeting we'll talk about what we found, what our care plan is from each of the three disciplines. There might be times where we're like, you know, from like an athletic training standpoint of there's no dizziness, they're walking 20, at least 20 minutes a day, it doesn't increase their symptoms.
Like they don't need to see us, they're good. Or, you know, psych, they is might, they might have a lot of emotional ability. So, or a lot of, um, trauma related to how their, uh, concussion happened. And so, you know, psych might be like. I need to see them for an hour for at least three weeks. So we're like, okay.
Um, or, or moving from there. And then our prolonged, um, can I, can I
Laura Wilson: pop in real quick though? Yep, absolutely. I wanna make sure to mention, so for our acute as well and our prolonged, [00:42:00] um, we also do the PHQ nine, um, which is a depression screener and um, also helps their risk assessment. So Jennifer did a lot of work in kind of thinking through how we were going to kind of check in on that because, um, that can be a concern post-concussion and frankly, and, you know, anytime in healthcare when we, when we see patients, uh, so, uh, general you talk about the, our kind of assessment, our, the emergency.
I was gonna say, yeah. Our risk assessment and that kind of thing.
Jennifer Steward: Yeah. Yeah. You read my mind, Laura. 'cause I was, I was gonna jump in with that too, so, um, so yeah, yeah, like what Laura was mentioning, like. Uh, certainly after a significant injury, like anytime like you have a big life upset, but certainly after like a, an injury, like a concussion, um, the risk factor for suicidal thoughts increase.
And so, um, and then if you have, you know, a physician or someone who's told you like, you're gonna be better in two weeks, and suddenly it's two weeks and I'm still feeling really awful, then um, that can increase some of that hopelessness as well. So we've seen it, [00:43:00] um, really in, in our older adults, in our, um.
Children and adolescents even. Um, so we've had to get creative with some of our measures, um, to make sure that we're assessing depression and risk related symptoms across the board. But we, when we were getting ready to open the center, we did a lot of work to kind of create a decision tree for what would happen if, like someone screens positive for, um, on that PHQ nine.
If they say that they're having thoughts of harming themselves, um, you know, who, who follows up on that? What, when do we need to kind of like, sound the alarms of, um, getting someone to do a, a full risk assessment with them more quickly? And so if, um, other providers are looking for some resources, a, a good one.
Um, in addition to the, the one question on the PHQ nine, if you're familiar with that one is, um, the Columbia. So the Columbia, um, suicide severity risk. Scale, um, is, I'm probably butchering that, that name. I might need to go back and, uh, look for that. [00:44:00] Um, is, is a really well validated brief measure that really any discipline can do.
It's been, um, rolled out. There's some, some good like YouTube trainings and things like that with, on how to other disciplines can use that in a number of different settings. Um, if you're encountering someone who's got some emotional ability, they're reporting, you know, some thoughts of harming themselves and you're like, Ooh, I need some more information, but I don't quite know how to, how to start getting that.
Um, that can be a really helpful, helpful tool.
Laura Wilson: I wanna jump in for a moment because back to sort of SLP training related to counseling and that kind of thing, um, I know people can feel a little bit nervous sometimes, but, uh, giving a measure like the PHQ nine, which is the patient health questionnaire nine, it's nine questions.
Um, and it's really just these questions they circle on a Likert scale, um, the patient does about how, how often certain things are bothering them. Um, it is absolutely within the scope of practice to give a screening [00:45:00] measure like that for an SLP. Um, and if you're gonna work with this population, it's really important to get comfortable.
I really like that one in particular because, uh, it has been validated on individuals with brain injury. Um, as you can imagine, there's some like symptom overlap between depression that is not, um, caused by injury, for example. And, uh, brain injury symptoms like sleep, for example. It can be disrupted because of concussion and disruptive, because of, um, depression as well.
So this one is nice because it has been like, uh, validated in the brain injury population specifically. So absolutely within skip of practice. And, uh, if you're going to use a tool like that, there needs to be a plan in place. So it is appropriate to give, but it is not appropriate to give without a, without a plan and decision tree in place because, you know, you can say like, oh, okay, well they are having, um, or they like, are showing up as like potentially severely depressed, or they're having these, um, suicidal thoughts, that kind of thing.
You have to have a plan in place and it's really not, um, [00:46:00] in, in my view, that shouldn't be a plan that's generated by a speech path, right? That should be done in consultation with our, our experts in, in that field. Um, so I would encourage folks to get familiar with tools like that and to think about who their resources are to help them think, uh, to think through that like action plan for after they, they use a screening measure like that.
Kate Grandbois: So that brings me to a question. I'm also thinking about our last learning objective related to developing a concussion center. When you talk about, you know, perfectly fine to provide this screener, but you need a decision tree, you need a pro a protocol that to me speaks to procedures, business infrastructure, uh, you know, team cohesion, collaboration related to specific policies and procedure.
And now we're, it kind of feels like we're starting to talk about how you develop some of these things. Um, I'm thinking about the SLPs who are listening, who are inspired by interdisciplinary, [00:47:00] uh, care. When treating individuals who have concussions or mild TBIs, what are some of the components that go into, like, what are some of the first steps?
How do you initiate. Building some of these things. Um, as you all know, speech pathologists, we are in schools, we're in hospitals, we're in private practice. Um, people with TBIs are in all of those places. Yeah. So I have to imagine that putting some, putting some thoughts, some of these policies, procedures, infrastructure, not necessarily developing a quote center in and of itself, but mm-hmm.
Uh, I'd love to hear your thoughts around starting to develop some of this stuff to put it into, put it into place.
Laura Wilson: I think it's gonna be pretty setting dependent, like you mentioned. So maybe let's start with school SLPs first. Um, and a lot of this is gonna be governed in part, uh, when you think about policies and procedures by state law.
Um, so, uh. All [00:48:00] states have some sort of concussion law on the books. Um, most states have concussion law that mentions at least return to learn. Um, not all of them, but, but many states do have some regulations around return to learn. And so these regulations are going to be heavily related to student athletes.
Um, but essentially many of these return to learn laws will say something like. Um, uh, they're, they're similar to return to sport, right? So you perhaps can't go back to the field or the court or whatever until you've got a release from a medical provider. Um, but the return to learn will say something like, there has to be a mechanism in place to support the person going back into the classroom now, how well this is implemented, how, how many supports are actually provided.
Um, that's, you know, that's a little bit tricky. Um, but that's one place. So if you are in the school and you're like, okay, I want to get a little bit more involved in this area, I would look up, I would recommend looking up the state [00:49:00] law around concussion, just to see what the expectations are. Um, and then I think, like Rachel mentioned, thinking about the stakeholders in the school.
School who, uh, might be interested in having this con this discussion about concussion. So, um, some folks that come to that come to mind, and it's not an exhaustive list, but, um, it'd be speech path. It'd be athletic trainer, it'd be the school nurse, be the school counselor, be the special education, uh, director.
And it would be, uh, an administrator as well. And then I always think anytime you're doing something in the schools that it's, uh, that you would like to have classroom teacher representation, just 'cause they're the folks that like, know what's going on and they're the folks that spend the most time with your, uh, the students.
Um, and I, I don't think I said coaches, but I think having coaches involved in that discussion can be really helpful. Now I know there's, like, I would even
Rachel Hildebrand: add. To that list. P-T-A-P-T-A, moms like the PTA president. Mm mm-hmm. Um, we've learned through athletic training, if you wanna get something moving, get the PTA moms involved.
Um, [00:50:00] so I mean, as, as, just if you're kind of like, if you're sitting writing a list, like include the PTA, um, president because they're, they're gonna be able to, uh, move the school in a way that maybe people internal to the school aren't gonna be able to do that they're advocating for their kid. Right. Like, so everybody wants to help the kids.
So
Laura Wilson: Yeah. So thinking, yeah, so thinking through those stakeholders, um, and then thinking through state laws and then any district policies and that kind of thing. And then a lot of it in the school is going to be about like the, I think some big questions to ask in those conversations. Or like, one, how do we find out that a kid has a concussion?
Um, it's, you know, easy-ish if you have good athletic training coverage and that kind of thing. It's easy-ish to know that a kid had a concussion at the school basketball game. This, you know, this weekend or Thursday night or whatever. Um, but is there a policy in place for how the athletic trainee trainer like disperses that [00:51:00] information to the rest of the school?
Is there a point person that finds out and then they disperse it? Or is it more of like a team approach and there are different models for that? Um, some, um, some school-based concussion teams will have like a point person who disperses. Um, some schools will have, uh, like several potential point people and it like rotates on a case by case basis to sort of like spread the, um, the workload a little bit.
And then some people will sort of do it based on like, uh, primary symptom presentation. So like, this kid had a concussion, um, they seem to be having the most difficulty with. Fill in the blank. Um, and so like that, so if it's more of like the cognitive stuff, then perhaps the speech path would take the, the role, or if it's more of, um, the physical stuff, athletic training or school nursing may take the role, the, the lead role there.
So there are a lot of models for that, but thinking about like, when, how do we find out and how are we dispersing information? Two, how are we kind of tracking their recovery, right? In those acute days, I, we really need to be, can I, oh yeah. Can I jump in there real fast there? Yeah, absolutely. Um,
Rachel Hildebrand: she [00:52:00] mentioned just, um, like it's easy-ish to know and we say ish because, you know, we're still relying on students to report, um, for the most part.
Um, but it's easy to know on those situations. But the, just to emphasize the importance of having the teacher involved, um, you might have a, a kid who's not involved in school athletics, um, it's club athletics, or it is at motor vehicle accident, and it's gonna be the teacher who first recognizes, um, this is not.
The same kid that was in my class yesterday or last week. Um, and so it's gonna be the teacher. And so doing, especially if you're an SLP in the schools, doing a lot of that outreach to the schools or to the teachers of, hey, like if you need a point person, let me be your point for, I know they're busy, I know they're overloaded, um, just like everybody else.
So I, I, I know that's a much easier thing for me to say than [00:53:00] school-based SOPs, listening to this right now, going, yeah. Right. I'm not adding another thing to my list. Um, but, you know, or, or having that, that, that, uh, group that maybe it is maybe the administrator, but really educating the teachers of here's who you go to.
Um, and then a, a point that, uh, Laura makes quite regularly that I just want to make on her behalf and, and please. Um. Elaborate on this. You know, even within what we're trying to educate our own professors at tu, um, when students have concussions, a lot that she'll talk about is, um, will you have this assignment?
They might be having a hard time doing this assignment. What your learning objective? Um, especially with students that might be experiencing prolonged recovery, um, that they're only in the classroom for half a day. Really working with teachers on what's your learning objective and how can you meet that same learning objective but in a different way.
So, um, and I'm totally stealing your thunder, so jump in [00:54:00] and cut me off at any it. Um, but you know, uh, if, if the assignment is to write a paper, but they're having a hard time looking at a screen because of bright lights and that cognitive load, can they orally, um, with a teacher one-on-one during a tutorial session like.
Give, basically give the paper to meet that learning objective. So those are kind of the things where I think, um, Laura's done a great job of educating our community as well as even our old professors on campus of how to meet still those same cognitive goals. Because as we see, and I'm gonna like jump into, I'm totally out of my realm right here.
Like this is Jennifer's realm at this point. But what we, what we have seen a lot, especially in school aged kids, is that the further they get behind in school. The more you see that anxiety go up, um, might even see that depression go up and then you see their concussion symptoms get worse and it continues to prolong.
So the more we can not get into that [00:55:00] cycle, um, the, the easier it is for them to recover. Okay. Now that I've totally stepped out of, nailed it, my, um, lane, you guys take over.
Jennifer Steward: Absolutely. Nailed it Rachel.
Laura Wilson: You know, I think one of the things that comes to mind and, um, you know, we're starting with like the school setting, but, uh, I found it helpful for teachers, for coaches, for patients themselves, for parents, just uh, for people who, yeah, those patients who like wanna get back to work is if we have that message like, Hey, I know it's hard, but if we take care of this correctly, and that's probably not the language I would use with it, but if we like, manage this well early on.
The probability that you get back to baseline faster is, is there, whereas if you're like, I know, but this, but I've got that, but what about this? And you push through, those folks are at risk for a, a prolonged recovery, um, in general. So, um, I know we have some students who get pushed back [00:56:00] from teachers who, you know, they're like, ah, they said I have a test, or they said I have to do the whole sheet.
And I think that message of like, you know, if we tackle it now, this is a short-term problem for most people. Um, that can go a long way with, with helping people like recognize that. Like, okay, I just need these, these brief accommodations. And so I think that's another thing with thinking about the, the school.
So when you're thinking about how to like launch this, you, this is a, a short term thing. So this is not like taking someone onto your caseload indefinitely. Um, this is saying like, Hey, we are going to need to do, you know. Ideally daily check-ins of symptoms so that we can adjust accommodations. And as long as we're staying on top of that, this is something that for the vast majority of people will get back to normal and people will be able to like, get back to their, you know, their kind of regular lives as they were before their, their concussion.
So I think, yeah, policies, procedures wise, school, school-based, check your obviously district policies, check your, check your state law, and then start thinking about who those, those stakeholders are. And then [00:57:00] essentially get a plan in place. Uh, the REAP program. Um, so that's REAP, uh, started in Colorado, but now has been adopted by a ton of states.
Has a really good, um, kind of model for what management can look like, uh, in the schools. And they've got a lot of resources. So if you're like, oh, I don't even know where to start. Um, if you, if you look for that, that's a, a really good kind of guide and things to, things to think about and again, who the stakeholders may be and, and that kind of thing.
So that's a good resource. Um. If we step out of the, oh, sorry. Go ahead.
Jennifer Steward: I was just gonna build on what you were saying with Yeah, please. The, going back to the active recovery piece. 'cause I think really what you're aiming for, especially with that acute phase, is like needing to hit kind of like a Goldilocks zone, right?
Because like, too much prolonged care could lead to like prolonged presentation, but also like rushing things too soon, right? Like trying to like, just kind of pushing through and like I'm just gonna, um, you know, jump back in and like hope [00:58:00] for the best, right? Um, and rushing those things too much can also lead to prolonged symptom.
Um. Presentations. And so trying to really find that, that spot where it's like your symptoms are going up a bit and then allow it to recover back down. And like Laura was saying, like those, that short term accommodation, right? Like this isn't something we are expecting for, for longer term. So, and then the, the psych role within that is typically like, how do we have those conversations?
So I think it can sometimes be a little bit easier on the side for like, if it's. With a school, with if, if it's in a, a setting where there's more likely to be a number of stakeholders or at least a, um, a person who can, um, advocate for the students. Um, it's a bit harder if it's an adult and they're needing to have a tough conversation with their employer about like, how do I accommodate my day so that I can help get these things back?
How do I go back, you know, maybe for a couple of hours and start to like titrate that up? Um, that, that becomes a much more challenging thing. So [00:59:00] how do you have those difficult conversations and like deal with the emotions around those, right? If I'm gonna go into my boss and say, I, I, this is what I'm struggling with, this is what I need.
Um, it, it's understandable for that to come with some, some pretty strong emotions, especially as I'm also trying to manage the stress of like navigating the rest of my life again. And, you know, the, the normative fear and anxiety that comes with like, oh, okay, I'm still struggling with this. How do I then try to work towards getting back to my normal?
So.
Laura Wilson: when we think about more either community, kind of outpatient settings or medical settings, it is, it's a, a different set of challenges. And I think that's largely due to, uh, funding, right? So then it becomes a, a, a challenge of like, who is the referral source? What does insurance cover? That kind of thing.
So I think, um. That's, that's probably outside of the scope of the conversation right now, just because it's so [01:00:00] complicated depending on your setting. So I think if I were a speech path in one of those roles, um, and I was interested in getting involved in this popula in, in working with this population a little bit more, I think the first thing I would do is make sure that I like, felt, uh, kind of clinically competent.
We can talk about some resources for that perhaps. Um, but then I think it's just making those connections. So getting to know the sports medicine physicians in your community, getting to know the PTs and OTs, uh, in your community. Um, starting to kind of like outline, um, what that role could be. And there's some, there's some really interesting, so, you know, when we talked about the role of the SLP earlier, that was a little bit kind of, um, in generic terms, but there's some really interesting roles that speech pathologists have played.
Um. I think about, uh, it's at, uh, Miami University where they've had a, a concussions, interdisciplinary concussion center there for over 25 years. And speech language pathologists are involved in, uh, baseline testing of [01:01:00] athletes, for example. Um, I think about we met some colleagues, uh, from Baylor who are in the process of working on, um.
Developing a motor speech based, uh, assessment to help with di diagnosis of concussion. Um, we have, um, talked to folks who work with the VA who do more like group-based dual task, uh, um, kind of interventions for, uh, for the veteran population. So there are lots of, there are lots of avenues there. So I think that it's kind of thinking about what the community need is and who those stakeholders are to figure out like what your, kind of like, what area you would like to, to focus and, and build into.
But again, just, you know, we don't wanna. Pretend like the, the financial component is not, uh, an important part of it. We're very fortunate, so I, I think it's important to be transparent about that. We have grant funding that allows us to, um, to do this. And our, our center right now, [01:02:00] our services are, um, free of charge to the, to the clients themselves.
Uh, so we have a lot of, a lot of flexibility that, you know, not everyone has for sure. So, again, if you're like more out in a community setting, I think first steps are making those connections. Um, you know, once you, once you kind of feel competent in this area, and, you know, that doesn't mean you have to be an expert, right?
Like, we all have to start somewhere no problem. But like making those connections and kind of thinking about, um, what the, the community need is there as well.
Rachel Hildebrand: And I think I wanna piggyback on something that Laura had stated with, um, I mean we were talking about policy or procedure development. Um. Being flexible.
Right. And realizing that like you're not gonna get it right the first time. I think we're, I don't know what iteration we're on in terms of like all of the different things, but I, you know, I. Just understanding that, like starting, just starting right. And then realizing like as you're making those connections [01:03:00] and learning, Laura and I started, um, at tu at the same time, and literally what I knew about speech path was Arctic.
Right? Like I, I was like, oh yeah, like you help little kids say ours. That's what you do, right? And, um, she was like, you give water. Um, so, you know, that's, that's where we started with each other. Um, I think when Jennifer was psych, we were like, uh, you talk to people we don't know, right? And so. Our ourselves, you know, we can talk a little more eloquently about each other's, uh, services at this point, but Laura and I have been working together closely for 10 years.
My first Asha that I went to, um, I was like, oh, you guys do that. You guys do this now, Asha literally is the highlight of my year. I love going to Asha, um, because I just learned so much that also applies to my job because there is overlap. Um, so I, I would just encourage people, um, that are maybe thinking in this space, um, even if it's [01:04:00] not concussion, but just interdisciplinary management in general.
Like just start, right? And, and just go to a, a different conference, um, and, and learn what they do and, and start making those connections. Uh, so that, that would be my like. I don't know, thoughts on how to get started. For our third learning objective, um, is, is just start, um, kind of set out and, and know that you're not gonna have it figured out correctly from day one.
Laura Wilson: I think another thing that we've pushed into, um, is we've formalized our kind of orientation a little bit more, um, both for our patients, uh, in terms of like, uh, kind of a manual that we give them, but also for like our student providers and new providers to the clinic as well. Um, just 'cause we found that, um, from both sides, our, our trainees and our patients, um, expectations are a little bit all over the place.
And so we, we [01:05:00] found that kind of doing some very upfront discussions about that has been really helpful. So from our, uh, patient perspective, um, we, uh, have been using, uh, goal attainment scaling, uh. A little bit more. And we do that, uh, as appropriate across the professions. Um, so essentially we're, we're working with the patients from the get go after their intake to help them identify goals, like functional goals, and then thinking about like within the time period that we're gonna be offering care, um, what sort of success would look like and what the metrics of success would, would be like for them.
So, um, that's been really helpful 'cause it, it, it kind of forces us to have that conversation about the timeline and about what is reasonable to expect for recovery within that, that timeline. Um, so that's been a helpful tool for us there. Um, on the provider side. We've, um, tried [01:06:00] particularly, um, related to that counseling piece.
Um, there, uh, we've talked a lot about, uh, like meta therapy, right? So there's a really good article on meta therapy related to cognitive communication, um, services. So it's essentially thinking about like, what is the patient's role in recovery and how can we talk about that, right? So if we think about like, metacognition, it's that thinking about thinking.
So meta therapy, it's like, it's thinking about therapy. So it's things like how do you help develop self-efficacy? Um, like what is the, what is the patient's role? How can we, um, make sure that they are, that we're like centering the patient's goals and the care, uh, and, and, and that kind of thing. So we've, we've leaned in on kind of training that and training some of those counseling skills.
Um. As well. Uh, and then just leaning into a little bit more kind of like rehab fundamentals. So using the, um, like RTSS, like what are, like, what are we doing? What's the [01:07:00] goal? And then like, like kinda what's the target? And then like, what are our ingredients? Why do we think that? Like what is the mechanism by which we think what we're doing in therapy is gonna make a change toward that target?
So I think we've kind of tried to start formalizing those discussions a little bit more for our, our trainees and frankly for ourselves. 'cause it keeps us all really centered. Like, uh, concussion management should be very functional in nature. Uh, right? So like, what are the presenting symptoms and how can we help support people with those?
How can we help people cope, the cope with those, and how can we help reduce those symptoms? Um, so in that way it's like, eh, it's a little bit black and white, right? Like, what's the problem? How can we all work together to solve it? Um. Again, what solving it means is gonna differ for each patient. Does that mean coping with it?
Does that mean understanding it? Does that mean reducing it? It it, it just depends on the, the patient and the symptom, but I think that we've like formalized that, uh, a little bit more just to get everybody's expectations on the, the same page. Um, and that's been really important as we've, [01:08:00] um, included more people, as providers included more trainees and kinda expanded our, our patient population as well.
Kate Grandbois: That's all so helpful. Everything that you all have shared has been incredibly helpful. I wonder just in our last minute or two, if you have any additional resources, thoughts, um, suggestions for any SLP listening who is excited by this topic? Would like to learn more. Where can our listeners go from here?
Laura Wilson: I, um, am, am not affiliated with them in any way, but, uh, resources from, uh, A CRM. So American Congress of Rehabilitative Medicine. Right. I think I'm getting that right. Um, so they have, uh, trainings that you can attend, but also, uh, some like treatment guidelines and that kind of thing that have been, uh, really helpful for me.
It's also like that's, uh, their tools are what I use. Uh, I teach the graduate, like cognitive communication disorders class, and so I use a lot of their tools to kind of [01:09:00] help structure the content that we cover in that class as well. So it's really, um, yeah, like kind of really straightforward all in one place.
So I would, I would say that's a really, uh, that's been a really helpful resource for me personally and my development. And in student training as well,
Rachel Hildebrand: I'll add a resource of the, uh, oh gosh, we're gonna do the same thing. BIA Brain Injury Association of America. Yep. Is that, yeah. Is a, is a great resource. Um. But I also wanted just say like, feel free to reach out to us. You know, part of our mission of our clinic is to, um, do just this, like educate professionals, educate community, um, help people get started, um, kind of learn from our mistakes, um, that we've made where we we're, we're willing to share them freely.
Um, and so I think reaching out to us at our clinic, um, is, is a [01:10:00] great way to, uh, to get started as well as a resource.
Jennifer Steward: Awesome.
Rachel Hildebrand: Yeah.
Jennifer Steward: And, um, for me, the, I remember the name of the, the measure that we are using for risk assessment. It's the Columbia Suicide Severity Rating Scale, so that people actually have the name of that. Um, and there's, like I said, training widely available for it. And then the other thing that we kind of briefly touched on, but we haven't really.
Gotten a chance to go into detail about, but it's come up with almost every single patient who we see is sleep, being able to assess sleep and to be able to work with clients to help them sleep better. Because, I mean, it's, there's a number of reasons why we think that sleep can get disrupted because of concussion and, and brain injury.
But we know in terms of recovery that like if you're not sleeping, nothing else is gonna be going well in terms of like your emotional mobility, your cognitive performance, your physical performance. None of it's gonna be where it needs to be. And so that's been a big role that, [01:11:00] that psychology has played with this as kind of being the kind of the central, uh, sleep people on the team.
Um, but I think any discipline can really do some work to educate themselves on some of the basics of, um, assessing for sleep issues. Just asking the question of like, how's your sleep been recently? And if it means a referral, then that's great if it works, if it's more, um. On sleep hygiene and how do you make some small changes to hopefully help increase their sweet sleep quality and quantity, then that's great too.
So, um, that's been a, a massive thing that we've, we knew was gonna be an issue with this, this population was, is their sleep. But I don't think quite even to the scale of what we've seen, where it's, it's really, um, to some degree almost every single patient that we've worked with has had something that we've at least touched on with that.
So.
Laura Wilson: I'm glad you said that because as you know, even though we've all worked together for a long time, we still still tend to see things through our own training and our own lens. And I think that something [01:12:00] that, uh, you just have to be a little bit like humble about is, is, you know, like Jennifer said, like if sleep is not good, then I'm not gonna be able to do much to rehab cognition, right?
Like, if someone is exhausted, I may do, you know, be using best practices related to cognitive stuff, but it's, it's not gonna matter. Um, and then I think the other thing, and just thinking about like what. To prioritize and, and what matters most is one of the, uh, strongest, uh, evidence-based interventions for concussion is early physical activity.
Um, now obviously as a speech path, I'm not gonna be the one recommending exactly what people should do in that kind of thing, but, um, if I'm seeing someone as a speech pathologist and I'm not like a integrated part of a team, I am going to say to them like, Hey, I would encourage you to talk to your physician about how exercise might help, right?
Like, I wanna plant that seed at least, because truly that, that, um, that physical activity, uh, is it sort [01:13:00] of like at all stages of recovery after, uh, an initial and see Rachel, now I'm getting outside of my wheelhouse, but, um, outside of that first like 24 to 48 hours, um, pretty much everybody, whether it's 48 hours later or two years later, um, should be engaging in some sort of, um, structured.
Aerobic activity. Now there are guidelines Rachel mentioned earlier, the buffalo concussion treadmill test, which is a standardized test to help, uh, determine what kind of exercise, what level of exercise you should be doing and that kind of thing. But really like sleep and exercise. Like those are the, those are the things.
And so, you know, those are not, um, strictly my wheelhouse for sure, but I need to be like, aware of that and able to at least mention to my patients that that is something that they need to consider because those things play such a critical role in recovery post-concussion.
Kate Grandbois: This has all been really incredibly helpful for anyone listening who is driving, running, folding laundry, [01:14:00] what have you. All of the references and resources that these amazing, brilliant minds have shared with us today are listed in the show notes. They will also be listed on our landing page. Um, if you've listened to Earn Ashe's, CEUs.
Uh, the link for the post-test will also be on our landing page, as well as in the show notes. Um, you all have shared so much great information and we are incredibly grateful for your time. I also wanna thank just quickly our team who helps to produce this podcast, which is a labor of love. Uh, quick shout out to Dr.
Anna Paul Mui, who manages our Ashes EU and makes those possible. Our production manager, Tegan Ahern, uh, who keeps our project alive. Darren Lopez, our production assistant who takes care of all of our marketing materials and, and web development. Tracy Callahan and Dr. Mary Beth Schmidt, who serve as consultants for our peer review process.
And last but not least, our advisory board who engages with the content review submissions and makes sure that our, make sure that [01:15:00] our content is high quality. Um, them plus you all, you all have shared so, so, so much. Um, and we're so grateful for your time. Anyone listening who wants to leave a review or send us an email or find us on social media.
Uh, we love hearing from you all. We will also list contact information and social media handles and what have you for the rest of our guests today who have very generously offered their time, um, to connect with anyone who has more questions. Rachel, Jennifer and Laura, thank you so much for being here.
This was really great.
Laura Wilson: It was great to be here. Thank you.
Kate Grandbois: Thanks for having us so much.
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.
Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of [01:16:00] the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at [email protected]
thank you so much for joining us and we hope to welcome you back here again soon.
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