Shall we get started? Good afternoon. Welcome to our panel discussion on using mental health screening and therapy to improve outcomes for work-related concussions. I'm Amy Peters, Chief Clinical Innovation Officer at Asellus Health. I'm a licensed clinician trained at Columbia University. Twenty-five years of experience in the behavioral health space and 13 in the tele and digital behavioral health space. I lead the clinical product evolution at Assellus as well as our outcomes work. I'm joined by my colleagues today, Dr. Dan Legoff, a neuropsychologist trained at Simon Fraser University in Vancouver. Dr. Legoff is a Clinical Quality Assurance Advisor at Assellus. And he leads and advises on all neuropsychological services that are delivered at Assellus. Dr. Miranda Cofelt is also joining us today. And she's a clinical psychologist trained at the University of Maryland, Baltimore County in psychology and behavioral medicine. She's also a specialist in the treatment of trauma and addiction. Assellus Health has been exclusively delivering behavioral health services to injured workers. And we have over 12 years of experience. Most of our care today is delivered via telehealth and we do provide services nationally. And today we have a full spectrum of behavioral health services for injured workers. So today's discussion is going to focus on the mental health screening and therapy for injured workers who experience delayed recovery post-concussion. We're also going to share the results of a study that we published in JOEM last October on this topic, on improving outcomes for this population. To warm us up, we would like to give us background that there are 4 million concussions that occur each year in the U.S. and 25% of concussions take place in the workplace. Psychosocial or psychological interfering factors lead to delayed recovery and lengthy claims duration. So for our learning objectives today, we're going to be distinguishing between the physiological and psychosocial symptoms resulting from head injury in the workplace, responding effectively to reduce functional impairment, and identifying situations appropriate for the referral for neurocognitive screening. We'll leave 10 minutes at the end for questions and look forward to our discussion today. Dr. LeGoff. Thank you, Amy. Yeah, I'm Dan LeGoff, neuropsychologist. I'm not a concussion guy. I probably have spent most of my career working with people with pretty severe brain injuries. That's an area I feel more comfortable doing brain injury rehabilitation, that sort of work. Concussion I kind of got dragged into, I think, partly because there was such a backlog of evaluations that were accruing, and my employer and employers had asked me to look at the problem of this enormous number of concussion cases that were stacking up and that we weren't getting around to. And our neuropsychologists were obviously backed up all over the place. So I needed something a little more efficient to try to get through the evaluations, and a lot of them were the kinds of cases you're probably familiar with in which there wasn't a lot of evidence of severe injury, but the cases did drag on. As I was looking at a cohort of probably initially about 100 cases of people who had bumped their heads in some way, got knocked on the head some fairly seriously, and some quite subtly, to put it politely. And some of these cases had been on our backlog of referrals for months and might be spending another three, four, five, six months waiting for a comprehensive neuropsychological evaluation on the order of the treating physician to clear them to return to work. So I thought, well, surely these people don't have any established clear evidence of brain injury. Do they need to see a neuropsychologist? Could we possibly just have them screened to see whether they still had residual features from their initial injury, and then discuss the option of returning them to work, which is what I immediately started working on. So in general, I'm going to be going through the process of what does it look like when you try to get quick screening of people with neurocognitive presentations consistent with either post-concussive sequelae or post-concussion syndrome, or as the ICD says, post-concussional syndrome, that you can get them back to work a lot more quickly than waiting around six months to get a comprehensive neuropsych done, or even longer to get, you know, a neurologist to take a look at them. What do I point this at? Oh, okay. So we're going to be prepared to distinguish physiological and psychosocial symptoms, and that's a big factor. A lot of the research shows that probably the predominant number of issues for delayed recovery from concussion have really not that much to do with head injury and more to do with psychosocial factors. Negative affect being the primary one, so anxiety, depressed mood, post-traumatic symptoms, anger, irritability, basically getting hit on the head makes people grouchy, and they stay grouchy for a while. That's kind of the message. To respond effectively in occupational medicine context to reduce likelihood of functional impairment, and I think a lot of things that we'll be talking about today are things that anybody could do. You know, I mean, we took a fairly sophisticated approach to this because we know sometimes there's lawyers involved in this process, and some of these people are off work for a very long time. There's a lot of secondary gain issues involved, so we wanted to make sure that we were doing a very careful, conscientious evaluation, and I, for one, was not going to hang my hat on something like the IMPACT, the sports concussion tool, to tell people to go back to work. I wanted a more thorough evaluation, but at the same time, I wanted something in between something like the MOCA, you know, some kind of brief neurocognitive screen, and then a comprehensive neuropsych, and there was really a big gap between those, so I'm aiming for something in between them, and that's what I kind of came up with. So today we'll be able to identify the cases in which that in-between approach might work well. So let's distinguish, first of all, between a concussion and post-concussional syndrome. First of all, I'll say right up front, I'm not qualified to diagnose a concussion. I'm a neuropsychologist. Concussion is a medical diagnosis. Post-concussional syndrome, on the other hand, you'll see it starts with an F. F codes are mental health codes in the ICD. A lot of my colleagues sometimes forget that, but it's really important to keep that in mind, that when you're diagnosing post-concussional syndrome, you're diagnosing a psychiatric condition, and my view of that is you're diagnosing something like body dysmorphic disorder. You know, you've got a little thing there, and it's not going away, and you're just getting really neurotic about that little thing, or like a somatoform disorder, oh, the elbow pain just won't go away, and it's going on and on and on and on, and now it's kind of taken on a life of its own, right? I've got an echo in here. So if you're looking at someone with post-concussional syndrome, you're really looking at the worries, the anxieties, the stress, the depressed mood, all those psychosocial factors combined that sort of take on a life of their own after the physical injury. So that's what you're diagnosing. It's not just a concussion that lasted too long, or a really bad concussion, which is a common misunderstanding, because most of the people who develop post-concussional syndrome didn't have very severe concussions, and if they have a really severe concussion, it's probably a good idea to get a neurology consult to rule out something scary, like maybe a hypothalamic pituitary injury, or an ascending reticular activating system injury, you know, so you could, there are some scary things that can happen to you when your head gets whacked really hard. Most of the injuries we'll talk about that are associated with concussions are actually extracranial, and that seems to be the crux of the thing I'll be repeating today a lot, is that people get really nervous that their tinnitus or their blurred vision or their headaches or their neck pain are signs of brain injury, right? But your brain doesn't get busy, and your brain doesn't feel pain, right? And your brain does a lot of seeing, but it's not the result of ocular motor activity. So these are all extracranial injuries that come from getting whacked on the head. And most of the symptoms that people worry about with concussion are really not due to changes in the central nervous system, they're not due to changes in the brain. Some may involve cranial nerves, and as you know, if you have a brain in a drawer somewhere at home, you'll notice that the cranial nerves are all clipped off, well that's because they're not part of the brain, except the olfactory bulbs, that's a little dicey, but certainly if the person can't smell, then you know you've got more to worry about than a concussion. So that's kind of the diagnostic area. The early risk indicators we have to worry about, I would say worsening symptoms is probably the number one one. In your first report of injury, the person comes in with a hand injury and they give you a list of complaints, and then they come back a week later, and their list of complaints pretty much exactly mirrors what's on the internet about post-concussional syndrome. And it's three times as long as the list of complaints they had when they first came to see you. So you're probably going to look at a little more complicated treatment history than just a concussion. Most of the literature does seem to highlight, at least the very credible literature, and not the ones that are just convincing people to stop playing football, but the really credible outcome research suggests that the main presenting problem that's complicating things is going to be more psychiatric or psychological. Mood changes, sleep disturbance, depressed mood, irritability, those things tend to be the factors that cause prolonged symptoms. History of previous concussion is something to worry about, especially if someone has a type of job. I've got a friend of mine, believe it or not, who's a professional bull rider, and he comes to see me about twice a year, and every year I try to talk him out of riding bulls, and every year he tells me he makes more money riding bulls than his whole farm put together, so he's going to keep doing it. But it's a repeated concussion, if you have that kind of occupation, if you're a professional athlete, that is something to worry about. Most of the time you're seeing someone who bent over to tie their shoelaces and bumped their head on their desk, that's not the issue, they're not doing that every day. Or someone tripped and fell and a bookshelf fell on them, that's not going to happen over and over again. So those are the kinds of injuries that we don't necessarily have to worry about, chronic traumatic encephalopathy. Very non-credible symptoms are something that you may hear. I've had people show up and say they can't remember their name, their phone number, or where they parked the car, and I'm like, oh, you drove here with no sense of memory at all, but you don't remember your phone number, but you knew how to get here. Lots of non-credible symptoms. People hear about photophobia, you know, 10 months after getting bumped on the head, someone shows up and after driving to the appointment said they can't look at the computer screen to do the testing because it's too bright, or they show up, they're sitting in your waiting room with sunglasses on, like, well, the light outside is 10,000 times as bright as this computer screen, that's not a very credible complaint. But we don't confront people with their non-credible complaints, we give them the good news that we don't think there's anything wrong with their brain. Quite often you'll hear people feel very resentful about the workplace, there's all kinds of other feelings about their employer that may come out when they get hit on the head. You may hear those things directed towards you if all you offer them is a bag of ice and some Tylenol after they present with a very serious problem, they have a headache from whacking their head, and you say, you should be fine, you've got a bruise. No, they want to hear that you're very concerned about their concussion and you're probably going to order a CT scan, but sometimes these things don't go away and they come back the next week with a lot more symptoms. So I think you kind of get the idea that these people are going to present with a lot of complaints, a lot of the, as I was saying, a lot of the injuries involve head movement, especially if you move your head, here's something just, you know, from physiology, you move your head approximately one mile an hour, you know, in usual movements. When you walk it's about two miles an hour, so if you walk straight into a brick wall you're going two miles an hour. The deceleration force from that type of injury is very low, so it hurts like hell, but it's not that dangerous to your brain, you know. So motor vehicle accidents or falls, especially falls from heights, a lot more serious problem for deceleration injury to the brain. If you're moving your head, you have these common injuries where people hit like the observational lamp and the OR, bang your head on a lamp, bang your head on something, your head's not moving that fast, so the deceleration injury to the brain is minimal. You're also not putting a lot of force behind it. You do see a lot of temporary CNS changes with concussion, I'm sure most of you are familiar with diagnosing concussions, so I don't necessarily want to spend a lot of time on this. The ones that are most obvious and easy to tell are loss of consciousness, especially if the accident was witnessed. That's a good sign. If people saw you fall down and you were unconscious and other people can verify that you're unconscious, that actually verifies the injury. But retrograde amnesia is something that people are sometimes inconsistent about, or even loss of consciousness. They'll say, oh yeah, I don't remember the accident at all, but I was unconscious for at least a minute. I woke up in the hospital, but oh, now I have PTSD from this horrible injury. So you get these stories about what happened to them. Exaggerated startle responses and overreaction to light and overreaction to sound are credible symptoms, but they're usually really brief in duration. They resolve within a day or two, most of the time. These are the types of symptoms you want to screen for. If they have a lot of these, you may want to consider getting a neurology consult. A CT scan may not show much, as we know, and even an MRI isn't going to show a lot of changes. So these are essentially invisible injuries and take a lot of detective work to figure out how much really happened, unless they have a lot of external injury to the head, bruising, other kinds of, you know, like lacerations, that sort of thing. So you know for sure if someone shows up with a big cranial bruise, they definitely whacked their head. Extracranial symptoms, that can be confusing to patients, and it's often really important right away to start reassuring them about this. Before you start reassuring people, make sure that they feel understood. That would be my one main takeaway point from this presentation, is don't start with the ice and Tylenol before you've told them, I get it, that must have hurt a lot. I see you were, you know, that really hurt. And they feel that their complaint was understood and they felt you took them seriously before you started reassuring them that there's nothing wrong with them. But dizziness, nausea, tinnitus, blurred vision, these are more or less in order of likelihood. Cervical strain is very common. Often underestimate radiating pain from the neck to the head. Myofascial pain is probably one of the most common ones that's often overlooked, especially if you have hit something really hard and you have a myofascial bruise or something. But cervical radiculopathy, basically neck strain and radiating pain, or in assault cases or other kind of facial injuries like falls where the face is involved, those are a little more dangerous, obviously, because the way the brain is structured into the brain pan, you got a lot more vulnerable hardware, including the cranial nerves, if you have, you know, the injury is directly to the face or jaw. And then dental and TMJ pain, again, from the same types of injuries. So lower face, lower jaw injuries tend to be a bit more dangerous than just the rest of the cranium. And, you know, most of you probably know the brain is pretty well padded in there, you know, the meninges aren't there for no reason. Like you have a brain inside a helmet, the external helmet doesn't really do that much for deceleration injuries, sorry, football. But the brain is actually fairly well protected. But there's a whole lot of other stuff in your head besides your brain. And that stuff hurts. The psychological symptoms we see a lot is the primary one, as I said, is kind of people get really grouchy. They're angry and irritable. They don't like getting hit. Anybody who's been hit on the head recently, if you walk into something, boy, it makes you mad. Tears in your eyes and you're kind of dizzy, you get a bit of shock, actually. You know, your adrenaline shoots up, it'll wake you up getting smacked on the head. And it lingers, you know, it's myofascial tissue really kind of, you know, and so you go, you get into a kind of a funk about it, especially if people don't take you seriously. One of the things I think is underestimated sometimes in workers' comp in general is psychological reactance. That's Jack Brehm's idea, if anybody remembers reading Jack Brehm, B-R-E-H-M. Psychological reactance is like the teenager syndrome. You tell them A, and of course they're choosing B. So sometimes people, if they feel as though you're pushing them in a certain direction towards, oh, never mind, this wasn't a big deal, go back to work, they're going to push back simply because they feel as though you're infringing on their freedom to make a choice. I want to make my decision about this. I want to decide what my reaction is going to be. Don't tell me how I'm supposed to feel, right? And that's the psychological reactance component to dealing with patients who feel as though you're not hearing them well enough to understand their point of view. How do you deal with that? Oh, how do we tell you deal with reactance? We'll get to that. We do talk about therapy eventually here. One of the things that's common, most people are up to date on this, that post-concussion recovery should not involve a lot of rest or avoiding going on the computer and all that. I mean, that's a bit old school. Getting back to usual activities as quickly as possible. If people have jobs that involve things that are dangerous, if you're a bus driver or you operate every machinery, probably not a great idea to do that right away, and maybe just to get cleared and make sure that you're functioning adequately. But prolonged rest is probably counterproductive for this population. Proactively addressing the negative emotions through active listening, very easy. Just pretend to be Carl Rogers and say back to people, oh, I see, this must hurt a lot for you. You're describing horrible pain. Or whatever their anxieties are, people are very anxious about things like chronic traumatic encephalopathy, and they may even say, you know, I heard about people getting hit on the head and it causes, you know, dementia or serious problems. You can be reassuring, but it make sure you feel, they feel that you hear their concern first before you dismiss it. There's some emerging research on vestibular therapy. It's mainly for dizziness and vestibular problems. Not that much to do with the central nervous system. And cog rehab for some reason seems to have been taken over by speech pathologists. I've been bumped out of a job as a neuropsychologist. I don't know what happened, but I lost that job. But cog rehab doesn't really have that much to do for people with concussion because most of the time you're in, your brain is recovering very quickly if there's any brain injury at all. And so most of the symptoms, as I said, are kind of extracranial and psychiatric. And kind of jumping the gun by going to doing any sort of cognitive rehabilitation for memory. Because most people with concussions don't have any problem with their memory. I can assure you that. Memory is down deep in the center of your brain and very few people get concussions that affect the cerebellum or other central limbic parts of the brain. There's not that much evidence that you're going to have a lot of need for cognitive rehabilitation after a concussion. As I mentioned most of these before, if there's witnesses, accounts of the injury, if they seek immediate attention, if you see someone coming in to be evaluated for a concussion two weeks later, it's a little questionable. If there's a lot of extremity injuries, usually people think, oh wow, that must've been a horrible fall, you know, you broke your arm. Well that just means all the force went to your arm and very little of it went to your head. Because there's only so much force involved in your body hitting the ground. There's gravity and the weight. And so if you have, you know, defense wounds from, or you know, other kind of bodily injuries, that means your body hit the ground before your head did. Falling objects, you see these a lot. Look at the weight of the object. I mean, the ACOAN has done a really good job working with OSHA to protect people from wearing overly heavy headgear. So if your welding mask falls and hits you on the head, it's because, and it won't cause a lot of injury because it's only allowed to weigh a certain amount. Like, there's a limited range of, like, hard hats just don't weigh very much. We see that all the time, you know, something falls from a shelf three feet and it weighs 20 ounces. If it hits you, calculate the force. It's not going to get anywhere near the level of Gs that you require to have interparenchymal changes in the brain. It's physics. But if objects are heavy, and I have a big fat file folder, because I used to work in British Columbia, on tree branches. What type of wood that they're made of, and how long they were, and how far they fell, and what part of the head it hit you on. So yeah, heavy falling objects, they can accelerate very quickly. The construction sites, a 2x4 falling from any certain height, that's a serious, potentially serious injury. You know, a welding helmet falling three feet, no. I actually have charts for all these things. So our model that we're going to talk about today is a brief intervention for concussion and post concussional syndrome. A lot of these people met us sort of along two paths. One is towards having mental health diagnoses, and so they were referred for mental health treatment. And I said before, post concussional syndrome is a psychiatric diagnosis. Others were referred to us through what's called HBAI, which is Health Behavior Assessment and Intervention. It used to be called Health and Behavior, and it's essentially requesting a health psychology consultation, or what some people call behavioral medicine or behavioral health. So I actually recommend that pathway for a lot of people who are relatively recent post concussion before applying the F code and requiring the claims examiner to open up a psych claim, think about it as a concussion with delayed recovery, and refer them for a health psych consult. That will get you a lot more mileage than going down the psych route, because now you've got a psychologist trying to treat them for something that may or may not be somewhat motivated by secondary gain. And I don't want to describe too much of that, but you get the idea. There's a kind of a long path that goes down that. And I know the, you know, the claims people don't like to see that. They know what psych claims can turn into, and so I want to try to avert that as much as possible. The brief intervention model includes an evaluation process, which I'll talk about in more detail, that I developed as a neuropsychologist, but can be implemented by general psychologists via telehealth. And believe it or not, this entire evaluation takes about two hours to complete, but it's very thorough. It includes a lot of very detailed evaluation. You get a lot of data. In a two-hour evaluation, you get like a ton of information about the person's functioning, including symptom validity testing, psychodiagnostic testing, screening for PTSD, screening for depression. All those are packed into one dense piece of information we get, and can be done by a general psychologist. Now, typically what happens is those evaluations are done with my oversight. So I would usually want to have someone, either neurologist or neuropsychologist, involved, and not just have general psychologists evaluating people with head injuries. As I mentioned before, there are some potentially very dangerous things that can come up, or unusual or unexpected. And in fact, one of the things I always remind my referring physicians is that in the process during this study, we found, I think, four cases off the top of my head who had neurological conditions that had not been diagnosed. They were actually comorbid. One, I remember, was an embolism. The other was Parkinson's. And there were two cases of dementia, who bumped their heads and were referred for a screening due to a concussion. And our screening test revealed, oh, this profile doesn't look like a concussion. It looks like there's something much more seriously wrong with you. And we referred them back to neurology. So this profile is very sensitive to both psychological and neurocognitive changes. So this is all the stuff that's packed into one of our little NCSE evaluations. And general psychologists can do all of this stuff via telehealth. I'm not a huge fan of computerized testing, personally. Over the years, as a neuropsychologist, I've always wanted to see people doing the test, because I get a lot of information from how they complete the test, not just what the test results are. One of the cool things I found was that the CNS Vital Signs, which is a US product, Thomas Gaultieri is the author. And he's actually a neuropsychiatrist, not a neuropsychologist. But he had a neuropsychologist on his team. But they did a really good job. I'm quite happy with this instrument. It's computer-administered, and it does a pretty good job. It's also very sensitive to effort. So if you are sandbagging on this test, it shows up very clearly. Because it measures not just the total score, but actually the duration of your responses, the types of errors you make, and a lot of other things that people aren't aware of. When they're doing the test, they don't realize that the computer is actually taking a lot of data that they're not intending to share. And so we can actually look at the normative rates of certain error types for people who are malingering on the test versus those who are actually taking it sincerely and have real neurocognitive problems. So there's certain patterns of error that we see in people who really do have problems concentrating, paying attention, processing new information, especially in the area of executive functioning. People who are trying to pretend they have a brain injury score very differently. And it's very clear on the CNS Vital Signs. When I see the results, it's quite black and white. You see someone who's sandbagging on this test, it's easy to tell. We backed that up with the MMPI, which also has measures on it. Two validity indexes in particular, one specifically for post-concussional syndrome, and one is for memory malingering. And you usually see a correspondence. You'll see these high scores on the MMPI validity indicators for post-concussional features, neurocognitive symptoms, along with memory malingering, in conjunction with non-valid results on the CNS Vital Signs. I mean, some of them are a little more obvious than others. Like people show up at the appointment, they draw there, and then they get a score of like, a standard score of like 30 or 40 on the CNS Vital Signs, which means that would be essentially the score of someone with dementia who got a brain injury. You know, like they just non-credible results. They really overdo it. So these aren't subtle indications. Now the symptom checklist 90 is also used to get a feel for those other affect components of depressed mood, anxiety, somatization. In fact, as we'll see later, one of the most common outcomes from this is a diagnosis of like a somatoform disorder, and it's more common than you'd expect. In addition to that, we'd use the Neurobehavioral Symptom Inventory, which was developed by the DOD VA system for self-rating of post-concussive symptoms. Further research on this instrument has showed that there is a validity indicator. So there's a 10-item subset on the NSI that is a validity index. So if you score very high on those particular 10 items, reasonable likelihood that you're magnifying symptoms. We also use the PCL-5, especially in cases where we think the person may have been involved in a traumatic injury. So motor vehicle accidents, assaults, that kind of thing. And then we use demographic variables rather than testing, you know, adding additional testing to calculate a person's pre-morbid IQ. We just use a demographic estimate, which actually works pretty well. So the person has an opportunity to sandbag on the IQ test. So basically, we just estimate your IQ based on your educational level, your vocational level, your age, that kind of thing. All right, take over Miranda. Dr. Kohfeldt. Yes, if you have a quick one. Yeah, I mean, when we do do this administration, it is on an individual basis. So even though it's not in an office all the time, and obviously COVID played a huge role in this, right? We rolled this out right along with that. It's just a coincidence, because we actually started doing this before COVID started, and then we just happened to be sitting on a neurocognitive battery for concussions when COVID hit. So then all of a sudden we had all these neuropsychologists asking if they could use the protocol, so it was handy. I think this is a quick question. If you mentioned, I apologize, it's great information. I love what I'm hearing. Is there a certain time or specific time after concussion when this should happen? Because some are probably just going to resolve, right? How do you know when to do the test? Do you do it on everybody? We're going to get to that. Okay, yeah, yeah. So the major goal of our brief intervention model starts with the screening, and then we're moving into intervention. So a major goal of this is clearly mitigating the tendency for our patients who are recovering from these types of head traumas to linger in the system, especially if you decide, okay, this person's not going back. It's dragging out. Now we're going to feel forced into neurology, full neuropsychological evaluation. How long does it take to get a neurology appointment, like an initial neurology appointment? So we really wanted to be able to provide some solutioning for that, and given that we found that the major thing that impacts recovery from concussion are mental health concerns, we want to be able to address those. So we focus on work focus, cognitive behavioral therapy. So this is, you know, thoughts, feelings, and behaviors. You imagine the little triangle of how those are all connected, and you make sure that you're inserting the work component. So the primary thing here is being able to build that therapeutic alliance, and this assessment does that. So it kind of already is an intervention in and of itself by the nature of the person investing a lot of time in interviewing the client, understanding what they're experiencing. That helps them participate fully in the testing, and so you're already kind of building that alliance. And then upon the session ending, you have a feedback session, and so you have the provider actually going over your results, telling you that you're okay most of the time, but yet also saying, but you still do have these kinds of things you're experiencing. Here are the coping skills that you can use to overcome those. How do we manage what we're experiencing versus feeling as though it's never going to get better or we're just in a terrible position? So supportive therapeutic alliance, the other big thing, obviously, to stay work focused is having their job description is really helpful. So when you're referring and setting medical records, if you can include that, that's excellent. It kind of backs up what the patient's telling us they do for their job. And then making sure you really have a strong psychoeducational aspect. So we're clarifying their symptoms and where the source of those symptoms are. You know, sleep is major. Major sleep disturbances. If you don't sleep, you have headaches. So your headaches may not be an impact of the injury itself. You may have had some initially because of that, but these ongoing headaches might have other sources and reasons for occurring. We know depressed mood, anxiety, those contribute to headaches. So how can you kind of, you know, psychologists and other mental health care workers are really good at kind of explaining and not minimizing what they experience, but saying that some of these other components are contributing to your ongoing concerns. So, you know, but within the context, obviously, of workers' comp, we do want it to remain work focused, and we'll go a little bit more into what that looks like and how we kind of stay on track there. All right. So some of the things, just to have a little bit more clear examples of what we're looking at when we do do the therapy. Again, post-concussive, and we'll get into our study. It's not really, in our experience thus far, very extensive. They usually get what they need in a brief amount of time. But we are looking at making sure that we're helping to distinguish the differences and the symptoms that they're having, like I mentioned already, kind of normalizing the experience that they have, emphasizing their resources and strengths so you don't get bogged down in all the negatives and what they don't have and what they need. Make sure that you find those positives and resources that they have and can use. From the outset, you know, we want to set the expectation immediately that we're looking at return to work. We're going to do it safely and effectively, but that is the goal here, and how can we do that to maximize your success and give them that sense of competency? Reframing symptom magnification. So a lot of times when people do exaggerate what they're experiencing, it's because they're not feeling hurt. And so we can say, look, your symptoms as they really are, they're bad enough. Like, they don't have to, we don't have to escalate it, but we are here to provide that assistance. And we can also kind of in a very pro-social and positive way address when they're kind of exaggerating what's going on. And the other part is, you know, pulling out those positive aspects of work, especially if you do have kind of an injury. They have this experience and they're asserting blame to the work environment. They're upset with their manager. They didn't get a good enough response. So being able to kind of reframe that experience for them. So when we're talking about CBT approaches, we're talking about looking at increasing their activity, both physically and socially. Getting them back to reducing catastrophic thinking. And another big thing we work on a lot is assertiveness. How can you assert your needs both to your employer and to your healthcare practitioners? Because there is this kind of sense of helplessness that they feel when they don't feel heard. And they're not very effective at asserting their concerns. And so we help them kind of develop the skills to do that. So going backward a little bit, we have created a system in which it really helps to formulate work-related goals. So we want the provider and the patient to collaborate in identifying what their goals are. And we look at four areas of workplace functioning. So work preparedness, stamina and performance, mental focus and flexibility, interpersonal interaction and communication. And the items on the forward from which they select treatment goals were based on extensive literature review with work-related disability. So drawing from DOL, ODEP, ACOM, and the treatment guidelines. And so that's where the items are developed from. We have the patients and the providers work together collaboratively to identify the items that are most relevant to their job functioning and are resulting in the greatest amount of limitation. So they do work on these goals. They develop them together. They track progress on this over time. And this is how we kind of stay focused on the work-related situation. And then this is just an example of how, you know, you would track this over time. So being able to look at pre-injury, baseline, current, and target scores and how they're doing. When they first develop their goals, they tell us how were you operating before. Now that you've been injured, how do you feel you can function now? The scale is from 0 to 10. And then what's their target for them to get back to work? All right. I went back. There we go. So now we are going to move into the study. Thank you, Dr. Kohfeldt. I'm just going to basically skim the study because we probably have some more questions. And the study is available, as we said, it's published in JVM. Kind of the big takeaway from that is, and was a bit startling to me, when I looked at the average duration of time from the concussion to the referral to us for a mental health screening was 10 months. That was the average. We had people who waited up to four years still having post-concussive symptoms. Four years later, they're finally, oh, maybe we should have a mental health provider look at them. The average duration of time it took us to go from the evaluation to having 98.7% of them back at work was seven weeks. The modal number of therapy sessions for that group was one. Most common outcomes, we did the NCSC and a feedback session and they went back to work immediately. Because we were able to convince them there was nothing wrong with their brain and they should just go back to work. And what they needed to hear was that someone other than their occupational physician telling them, there's nothing wrong with your brain, you can go back to work. So we kind of back up the occupational physician's opinion by saying, you know what, we gave your brain a pretty good workup there. Wasn't that test pretty hard? Yes, and you're doing fine. You're ready to go. And typically, the reassurance, I mean, we offer them psychotherapy and some took us up on it. And one of the interesting things, and I haven't quite been able to explain this to myself yet, is it took even longer for men to get referred to us than it did for women. That was one of the few differences I saw in the population was a gender difference. That occupational physicians were quicker to refer women post-concussively to mental health than they were men. And the men participated in therapy very briefly, about three, three and a half sessions, and the women got about 6.5 sessions total. For the ones who came, most of the people who were referred to us, over 100, had a concussion, came to see us, got this evaluation, got the idea, and went back to work immediately. And I'm talking within days, after being off work on average for 10 months. So this was a pretty dramatic change. And I just want to see if we have, here we have the mean duration from the date of injury to the date of referral across the different subgroups that we had. Some were psychiatrically diagnosed and some were not, and male and female. But overall, you can see it's a pretty long time. From the date of referral to return to work in days was much, much less. So here's a direct comparison of those two, all right? How long it took to get to us and how long it took for them to get back to work after getting our evaluation. On average, it was 202 days overall, and an average of 33.7 days post-assessment to full-duty return to work, 98.7%. And this one is getting into t-test comparisons of pre-referral and post-referral last work days. Obviously, those are all different. I don't think I need to overemphasize that. This is the reference, which just seems to be in an unreadable font. But the general conclusion was, you can read it there. But it's not a bad idea to get a mental health screening and some support. Work-focused CBT seems to be all the rage, and I'm a big fan myself. The forward instrument helps with that, right? The forward instrument helps with that process because it narrows the focus onto work-related or work-relevant outcomes for people who have these psychiatric reactions to getting bonked on the head. And honestly, a lot of the people that did our evaluation were probably magnifying their symptoms, to put it mildly. But we didn't spend a lot of time telling people we thought they were malingering. We gave them the good news. You're ready to go back to work. Your brain is fine. Yes, you still have ringing in your ears, perhaps, but that's not your brain. That's your ear. Okay. Question? Yeah, let's time for a question. Were there other psychological findings when you admitted that you started psychotherapy or office psychotherapy to two others? These are the findings. Yeah. I just remembered, we had a couple of other people. There was a couple of the cases where people had comorbid physical injuries. And two included hypoxia. Firefighters who had falls and smoke exposure. And the results looked more like hypoxia than the falls. So, we were able to clarify that. So, for most people, we were able to do a fairly good job with a brief assessment. And as you know, for any of you who've been in that situation, waiting for a neuropsychological evaluation to get done can be a very long process, and you would expect the person to get better. But since they're being paid to be off work, sometimes they don't get better. And waiting for a neuropsych seems like a very good excuse to stay home. So, the turnover rate on this was pretty good. Some of our administrative staff and I got this down to, we were on a roll, and we were turning these over within a week, getting these evaluations done. So, we got through that backlog of people who had been off work for a very long time and got it down to, you know, just a pretty, to a trickle. These valuations have really slowed down, and we've been able to get through the backlog, and now we come in and they get processed right away. We do a neurocognitive screening, usually within a week or two. We're giving them the good news that they don't have a brain injury. If people ask questions, repeat it in the mic so the people not live can hear. Yeah, so, I know we're like over time already, but... No, no, we're good. We've got 15 minutes for questions. We did it. I know that nearly half is still listed as post-concussive syndrome. So, what are you saying to them? You're saying, you do have post-concussive syndrome, or you had a concussion, it's now resolved. This tinnitus may be a result of that, but your brain's okay, so go back to work. Yes. Well, I mean, unless the primary physician decided to hold them out because they had tinnitus, but there was no reason to hold them out because of a brain injury. So, most of the people with post-concussional syndrome, if you recall, have a lot of affect symptoms, and we offer them treatment for that. And some of them take us up on it, and they get better very quickly. Most of the time, they're very anxious or they're having sleep disturbance, and we provide them with supportive psychoeducational therapy, and CBT, sleep hygiene, and basic regimen and routine, take some melatonin. They improve incredibly quickly. When they are reassured that this isn't a serious problem. When you do that, do you make a comment if you think that the diagnosis is related to the work injury or not? Oh, causation? Well, usually the referral source does that, especially in the situation where we're the secondary provider. So, if we're doing an HBAI consult or health psychology consult, causation is up to the person who referred them to us. In some cases, they come to us as a transfer of care, in which case we do offer an opinion. The cause is usually fairly clear. The person fell down or bumped their head in some way. Well, let's say the adjustment disorder or the other diagnosis that you found. Right. Well, we're pretty good. Most of our providers have been coached by me to identify comorbid conditions and refer either to their own private practice or to someone else's private practice, and we'll see them privately if the issues are comorbid. It quite often happens that people have a lot of stressful things happening in their life during COVID and whatnot. And, you know, many other things could be happening. And then you get a concussion and it makes it much harder to recover. If you're going through a divorce and you whack your head while you're moving away from home, I mean, your recovery is going to be very complicated. But we don't treat that under workers' comp. We say, OK, well, we have some, you know, private referrals for you. So the neurocognitive screening and validation, is this something that, like, a psychologist can do? Yes. I train them every day. So, let's say... But the access. But the access to other people doing it, right? Oh, oh. At this point, we're doing it, but... Well, in order to access these tests, you would need to be at least a psychologist, unfortunately, yes. You'd have to be a general clinical psychologist. Well, the psychologists around my area know what I'm talking about. That's my question. Not this model. No. No. No, this is a proprietary thing. Just to let everybody know, the questions that are being asked right now will not be caught on the recording. OK. If you want to wait... So that question was... The question was, would the psychologist that you are referring a patient to know what a neurocognitive screening evaluation is? No. But you could direct them to the article. And most competent psychologists would be able to figure that out. I mean, Les Curtais could do it. Les is already doing it, I'm sure. He's like... Dr. Curtais. What I was going to say is that if you know what the components are... Yes. You can certainly do those tests. I mean, they're not... None of those specific tests that I can tell are... Proprietary, no. Right, right, right. So the only part of this whole package that is ours, that we developed, was the FORWARD, which is the treatment planning tool that we use to identify work-relevant psychological limitations. So for our contracted providers, we request that they use the FORWARD to help identify treatment goals and to track them in therapy so that they're working on work-relevant issues. For me, it's a very important issue because a lot of times with physical injuries, it's clear, or relatively clear, how the injury is limiting the person's capacity at work. In psychological injury, that's much harder. How much does depression limit you? Most people who are depressed still work. So why would you not be able to go to work if you're depressed? How would it affect your... We have to sort of do some work to translate psychological symptoms into functional work limitations. Well, that's what the FORWARD is supposed to do. We establish that the person has some kind of diagnosis, and then we tease out, how does this mental disorder affect your ability to do your job? Here's your job description, and these are the items on the FORWARD. How is your job being affected by these psychological symptoms? If not, then okay, you can go back to work. Otherwise, we're going to figure out what are the limitations, and then we target those in treatment. Thank you for your presentation. It's certainly pertinent information for all of us. I think that it's a great foundation, and I'm wondering what you think resources are that would be needed to replicate this in other areas where we don't have access to similar types of intervention. That's a great... Or do you have a plan to expand this implementation? I've actually got in the works a study that I'm going to publish similar to this one on using this model with brain fog. Delayed recovery from COVID due to neurocognitive symptoms. I couldn't wait to start using this tool because a lot of the symptoms I was hearing from people who had delayed recovery due to COVID were reminding me so much, even the dynamic of being very, very worried, like people who are recovering from deconditioning due to COVID, so their lungs are fine, cardiology has cleared them, pulmonology has cleared them, but their physical therapist can't get them to do much, and they're very hesitant, and they're anxious, and they're worried, and they're depressed, and they're not sleeping well, and they have all these other psychosocial factors that are combining in this. One of my favorite words, and you're going to hate me for saying this, is anturgy. Anturgy is defined as any problem... No, the result of adding lawyers to any problem. It's the opposite of synergy. So synergy is what happens when all the different elements come together and something innovative is created. The synergy of many different diverse elements coming together. Anturgy is when a whole diverse array of factors combine to create something that's new and startlingly impossible to overcome. And so I think the contributing factors of post-concussion syndrome look a lot like the similar sort of group of factors that combine together to create delayed recovery from COVID. So I was interested in looking at that. We have time for one more question. I have two questions. When you get an enabling physician and they're in ocular rehab and they have their convergence disorder and they're in speech therapy and they're in vestibular rehab and their neuropsych is normal, how do you handle that? Is there a special way you have to... Does that take more work? That's a difficult one. Most of the time, the people who are referring them to us for this want to know what the results are. They usually have to push a little bit because this is not a standard type of thing. Now, of course, under utilization now, neurocognitive testing is accepted as part of the utilization review under concussion and post-concussion syndrome, certainly. So usually they want to know what the results are. And if we give them the feedback that the person's cognitively functioning well or that they're magnifying their symptoms, they usually think about it. I would say that's about the best I can do. At least they take it into consideration. You do some therapy afterwards. You do a couple of CBTs. Are you doing a lot more CBT with those? No, that didn't really happen. I think the range of therapy sessions we had in this study was from one, which was the mode, the most common outcome was one therapy session, to 20. That was the max. The average for people who attended therapy, as we said, for men was three sessions, for women it was like six. 5.5? 5.5. I mean, there were low numbers in terms of the therapy involved. And as I said, the duration of recovery was very quick. The average duration of recovery post-NCSE was seven weeks. Did you have risk factors for those that were going to take 20 sessions? Usually it's comorbid or premorbid psych, in which case we are not necessarily treating a comorbid condition, but it certainly is a barrier to recovery. So people who have psychosocial stressors, other life events that are happening comorbidly with the concussion, or they have pre-existing psychiatric illness, that would probably be the number one. Some people haven't explored this, so is EAP a good start? Employee Assistance Program? Well, here's my note of caution. Here's my note of caution about that. If you feel as though they were upset with you for just giving them that bag of ice and some Tylenol, if you send them to EAP because they're going to say, you think I'm crazy because I got hit on the head? They don't respond well. They need to feel as though you're really taking them seriously. And this is just enough that they feel as though they were really heard. And I think doing much less than this, like just doing a mocha or other kind of brief neurocognitive screening, follow my finger, count backwards from 100, they don't feel as though you really gave them a good look. And I think this one just hits that sweet spot of it's more than a screening, it's less than a comprehensive neuropsych, it doesn't take that long, and the people do seem to really respond well to it. So I just want to go back to my prior question. So this study, you said it was 10 months after the concussion, which is when the concussion occurred. On average. I'm assuming, maybe I'm wrong to do that, but that's not ideal. What is the time period at which ideally should you intervene? A week. If you do the first PR, I don't know, in California it's called the PR2, your first follow-up visit, if they're not showing a dramatic improvement, consider it. So this is kind of in reference to an earlier question. You mentioned telehealth. We were wondering about access to this type of service. Is this something that anyone in any jurisdiction can refer to? Yeah, we have providers in 50 states. How? How do we get access? We can cover that after, but I think we have one more question. So I work for a hospital system, and we also link up with a psychiatric hospital, so most of the concussions I see are assault cases. So I get a lot of PTSD, trauma, psych, that kind of intervenes. So a lot of them, I send them to trauma psych right away because they're afraid to even walk to the doors of the hospital. I don't know, I'm just kind of curious your thoughts on that and how that interplays with this. The evaluation does include the PCL-5, the SCL-90R, and the MMPI, so we get a pretty good picture of what their psychological functioning is as a result of the injury. PTSD was one of the diagnoses in this study, and probably would have been one of the conditions that resulted in longer therapy. In my view, post-traumatic stress disorder is responsive to brief therapy if it's done well. This idea that post-traumatic stress disorder goes on forever is a bit of a... No. That's not a good situation. So in my view, and certainly in the DOD, VA system, six to ten sessions is pretty standard for trauma-focused cognitive behavioral therapy. I won't get into the whole nitty-gritty of which therapies you should be using, but there are trauma-focused therapy sessions. There's lots of best practice guidelines that are published by the American Psychological Association and the DOD. We follow those guidelines, our providers do. Usually with the assault cases, one of the main worries is that they have a brain injury, especially if they have residual cranial symptoms, dizziness, tinnitus, headaches, neck pain. They're thinking that those symptoms reflect brain injury, and that's very scary, especially on top of the PTSD. Now one thing I will caution people about is if you do have post-concussion syndrome and you start doing trauma-focused CBT, it does take longer, because the person is going to have a harder time processing the information, may not be as receptive to cognitive behavioral therapy. I don't know if anybody here has ever done cognitive behavioral therapy, but you have to be able to think clearly to do it. Especially with PTSD, essentially what you're asking someone to do is create a coherent, rational narrative of what happened to them without getting emotionally traumatized by it. That's very hard to do when your brain isn't working clearly, so quite often we hold back on doing something, especially like EMDR. Don't overemphasize that, really. We are at the end. Now I'm just getting excited. But PCS and PTSD are as complicated. The last thing I just wanted to say, and this also came up on the screen over here, was that these measures do have to be administered by a psychologist. These are all tests that you do have to have that background and those credentials to do that. Other providers typically cannot, but when you're looking for providers, if you're not referring to us, for the assessment and treatment, you want to call, when you're contacting psychologists, ask them, are you familiar with cognitive screening? Is there anything, here's information about a particular, you know, talking about the case with them a little bit and saying you'd like some screening to see if they offer those services. Having a background in health psychology is really important. Obviously being a neuropsychologist is important, and sometimes you can have a consult, and a full-scale battery may not be recommended or as needed. So just kind of finding someone who has experience in neurocognitive testing. They could do something somewhat different. It won't necessarily be this. Okay. applause applause applause applause applause applause applause

mental health screening

therapy

work-related concussions

psychosocial factors

recovery

Assellus Health

telehealth

delayed recovery

post-concussion

neurocognitive screening