We'll go ahead and get started, pull up our slides. My name is Carrie Wisner, and I'm the Assistant Director of Epidemiology at MD Guidelines. Thanks for coming to our talk about mild TBI, the prevalence, impact, and of the ACOM treatment recommendations and challenges with return to work. Can I get a raise of hands of how many people see concussion or mild TBI patients pretty regularly? Aye. Everybody. Thank you. My co-speakers are Dr. Shane Gernay, who is the Assistant Professor and J.D. Irving Endowed Chair of Occupational Medicine at Dalhousie Medicine, New Brunswick. He's also a physician and OEM of OEM and PM&R at the Department of Medicines at the University of Toronto and Dalhousie University. We also have Dan Jolive, who is the Workplace Possibilities Practice Consultant at The Standard. I'm an employee for MD Guidelines. We're the sole proprietor of the ACOM Guidelines, which we'll be talking about in this presentation. The others do not have any financial relationships. So today we're going to kind of cover some pieces about the research that we're doing, some demographics of worker compensation study that we're working on, and we're also going to identify common treatments that we saw in this population, and then I'm going to turn it over to our speaker, our other speakers, who are going to talk about the more clinical side and return to work. We're going to focus on jurisdiction and health system information as well to kind of give some context to TBI. All right. So in the U.S., we see 1.7 million people sustain a TBI every year. Most is mild, which is the good news, but 20 to 50 percent of patients experience limitations three to 12 months after their injury. This can be fatigue, headaches, inability to maintain previous workloads, behavioral issues. Work-related TBI, so that's you got injured at work, got your TBI while you were working, is about 18 percent, and we see it a lot in education, healthcare, construction, manufacturing, and transportation. Often it's caused by falls, being struck, vehicle crashes, and assaults. So that's what you guys are seeing every day. So for our study, we focused on mild traumatic brain injury. I don't know if you guys have looked at the ICD codes for TBIs, but there are a lot of them, and it's kind of all over the place. So in addition to the diagnostic groups, which there are 11 of them, you also have to qualify how much loss of consciousness a person has. No loss of consciousness up to 30 minutes, three minutes, 31 minutes to an hour, one to six hours, six to 24 hours, 24 or more, and unspecified for every diagnosis. On top of that, you have to define if it's an initial encounter, a subsequent encounter, or sequelae. So there are hundreds of TBI codes, and what people are coding and billing and all those things impact research. So based on the World Health Organization Task Force and a lot of the research that's out there about mild TBI, our study focused on concussion and no loss of consciousness or up to 30 minutes. So I'll refer to mild TBI, and that's what I'm talking about. So for our study, we used a retrospective cohort of 10 years of worker compensation data that was across California's system. We did 2009 to 2018. We specifically excluded pandemic years because that affected the aspects of people getting to work as well as the care. So we just looked at before of that. We also restricted it to those aged 18 to 65. They didn't have only the sequelae. So again, when you're qualifying the ICD codes, that initial encounter, subsequent encounter, sequelae, a lot of people had all of those, but if they had just sequelae, we did not include them. We also removed deaths, and we really wanted to look at durations. How long people are away from work when, based on their demographics as well as the treatments that they got. And we looked at the ACOM guidelines to see if treatments were recommended or not based on evidence. So we had about 23,000 cases in our study over a 10-year period. So this is a breakdown of each bar is a year. So we start in 2009, and we go all the way up to 2018. And you can really see a swing in the number of cases. So they're increasing by a lot. So that was worrisome. And then we also looked at the rate per 100,000 claims. So again, for the California worker compensation data, of all claims, how many are TBI? And you also see that gray line kind of matching that same curve. So it's not just due to population. In 2015, which is just past the halfway mark on the graph, that's when the ICD-10 codes were published and started being used. So was there some misclassification bias in the ICD-9s? Was there some in the 10s? There could be playing around in there a little bit. But I think overall, we can see this trend is going up and continuing. Here's a breakdown of the demographics of our cohort. It was more men, median age of 43, a median income of $36,000. Nearly all were urban, and a lot of people worked in retail or light and medium jobs. We compared this to Canadian studies that also looked at mild TBI. And our cohort was closer in gender ratios. So again, usually in previous literature, it's mostly men, which is what we saw. But ours was closer when we looked at just mild TBI. Our cohort was also slightly younger, and then in different industries. We saw a lot more people in retail, which we have not seen in other groups that could be specific to California. They're pretty generous with their benefits, that they'll give worker compensation to a lot of people, but they don't give a lot of benefits to very many people. So we captured probably a lot of reporting, but not people that are going to be in the system for a long time compared to other areas. So we're interested in why that retail was a little bit higher in the California, and why that hasn't been seen in other groups. Next, just some information about the general injury stuff. So the causes were falling or flying objects, slip, trips, and falls, struck or injured, stationary objects on same level from different level. These are decided by the person that fills out the form. So they're not as standardized as the ICD codes, which are more stringent about what they're including. But you can see the breakdown is kind of all over the place a little bit in each category. I want to draw your attention to the diagnosis category. So remember I said that we did concussion as well as mild TBI, no loss of consciousness, or up to 30 minutes of loss of consciousness. Almost all of it was concussion at 90%. So that's really driving a lot of the trends that we have seen in this group. The comorbidities, about a third of the group had comorbidities. So two-thirds didn't, which was good news. But we want to look more into how these comorbidities are affecting people. This data set doesn't capture if it was preexisting or diagnosed at that time. It's just a snapshot of the data. So we want to look at what those are and how they're impacting outcomes. And then if you look at the return to work section, so we had almost over a third of people did not return to work. So that's in that no category. And this is just that they were lost to follow-up from this group. They could return to the workforce in another area, but they did not return to work at their employer where they filed this claim. But 62% did return to work, and we looked at their duration, how long they were out of work. And so the median was 72 days, but the range, the IQR, so the 25% mark to the 75% mark, was 9 to 345 days. It's a pretty big spread for people that have the exact same diagnosis. So we thought that was pretty interesting. And then the medical cost was about $10,000 per claim. So this is only medical cost, not like salary or those other pieces. Again, $10,000, but ranged from $2,000 to $42,000, that IQR. So then we wanted to look at those comorbidities. We're calling them coexisting comorbidities because we're not sure if they came before, but they were included in approved worker compensation claims. You can see they're kind of all over the place again. A lot of MSKs in that 17% range, but then a lot of pregnancy ones. We also had cancer diagnoses in there. We thought that the mental and behavioral ones would be higher because we know that anxiety and depression can complicate care for mild TBI. So we're interested to see how this kind of plays out when we do more in-depth pieces, but then these are not exclusive of each other. So again, we had a third of the people had comorbidities, and this is the mix of all of them. So some people had a lot of comorbidities and some people only had a handful. So we plan to qualify that a little bit further in other research. You can see on here we excluded some of the other smaller groups that aren't really what I would call comorbidities or coexisting conditions, like the external morbidity codes. Because again, our whole study is based on ICD codes. So just for some context about some of these things, I want to talk about social determinants of health. The industry norms, who's reporting, why it matters, how employers, how unions, how insurance, sick time. These can't really be teased out from this data. The industry norms are, I have to report this and I'm going to move forward and go get looked at by my physician. Maybe it's the other way. I can't take any time off to go talk to my clinician. You know, my coworkers wouldn't like that, my boss wouldn't like that. So we're not able to tease that out, but I do think it's worth discussing because it's important. Also healthcare policies in the U.S. One of our collaborators is from Canada, and he talks about the care that they get up there and it makes me want to move to Canada. So I think some of the healthcare policies are really coming into play with this cohort. And then awareness of TBI. In the past, you know, 10, 15 years, more people are aware of TBI. Either patients thinking, you know, I hit my head, I should go get this looked at. Or clinicians recognizing those TBIs. Or employers making policies to say, if you have a head injury, let's get this looked at so it doesn't get more severe. And then in the U.S., people with disabilities aren't always treated that well. And so with concussion, it's more of an invisible syndrome. And so people may be under or over-reporting their symptoms or their ability to go back to work. Maybe under or over getting support from their employers. You look fine. Why aren't you working? Or I know you got a concussion, like, please don't work. They kind of go in both directions. All right. My next piece is I'm going to really drill down on the ACOM clinical guidelines and the recommendations we found in this cohort. So the ACOM guideline has a treatment recommendations for acute TBI, which is a little bit different than the mild TBI that we focused on. So there are some pieces that don't quite match. But you can see a screenshot on the right of all the A and B quality evidence. So the ACOM guidelines rank things as strongly recommended or strongly not recommended based on high quality evidence. When the literature is not there, it goes more towards the middle to be like, maybe this is recommended. Really use doctor's choice. And I use in the middle that there's no recommendation. Use with caution. Almost like stoplights. Red, don't go. Yellow, doctor's choice. Green, these get the gold star from ACOM. Here is a snapshot of the C quality evidence. So you can see more. There's more here than compared to like the A and B quality. But again, it's getting that C recommendation from ACOM. Like there's some evidence, but it's not the best. There could be more. We would like more studies. And then after the C, there are pages and pages and pages of treatment options that have insufficient evidence. They've never been proven to help or harm patients. They're just out there. It's being used in practice, but ACOM just doesn't have a recommendation on them because there's just not enough research about there. So how does this apply to our study? We looked at the ACOM clinical practice guidelines for our cohort, and we found that the median prescriptions per person was three, but that 50% of the prescriptions fell under that no recommendation due to insufficient evidence. So again, there's pages and pages of insufficient evidence for treatments, and that's what people are giving out because there's not good research either way. There was a median of nine services per person. So services include, it's pretty much everything that's not pharmaceutical. So that could be diagnosis, that could be treatment, that can be behavioral stuff all grouped together. The median was nine services per person, and again, that interquartile range was 2 to 28, and 30% of those fell under no recommendation. The good news here is that there's a lot of recommendation, or most people are getting the yes recommended. So ACOM has said, these will help people. We're seeing a lot of that, so that's really good news. And then also that the not recommended stuff is not going out that often. Only 5% of the pharmaceuticals and 12% with the services. So that's good news, but we're really interested in those kind of gray areas, the research that isn't available for those treatments. Can those be focused in more so that research options like clinical studies can be focused on those pieces? That's what we really wanted to find out. So these were the top prescriptions that people got. We classified them by drug class, so you can also see the same stoplight coloring. Red is not good, green is good, and yellow is kind of doctor's choice. But the biggest group in here is those NSAIDs. 60% of people are getting NSAIDs, which have no recommendation. It hasn't been proven if it's good or bad for mild TBI or acute TBI, but a lot of people are getting them. Here you can see a lot of green on the top services, so that's good news. A lot of these are recommended by ACOM, which is positive, only a handful of red ones. You see on here a lot of I's, those insufficient evidence. These are treatments that are going out to patients, but we just don't know if they're helping or harming. You can see it's the most popular down to the least popular, but physical therapy, yes, it's recommended, but it's getting insufficient evidence. There aren't enough studies out there. So you can see there's no A quality evidences on here, and only one B evidence quality. So how is this impacting outcomes? So we had said that the median duration was 72 days, arranged that curve around it as 9 to 345 days. Again we're only focusing on the people that were able to return to work. But what if people only got recommended services? People that only got green, yay, from ACOM services, they actually had longer durations. It was 187 days versus 168 days, which is not a very big difference, especially compared to like some other conditions. But what was really interesting is that when we looked into those services, the people that got recommended services had much shorter durations, 23 days versus 168 days. That's a huge difference. However, if you notice in this group, we have on the services for recommended only, 47% of this group didn't return to work. So why are people that are getting recommended only services not go back to work? We kind of had some hypothesis based on clinical stuff. Maybe they only got a few services, they got their diagnostic interventions, and then they quit or retired. They could have been the very extremes, those super short durations. In here is the category also of zero days duration, people that didn't need to leave work but have a claim, because again, California is very generous with some of their benefits. So a lot of those zero day durations could be driving this. Also for earlier referrals, so if people are getting only quality evidence based things, maybe they're getting earlier referrals, but for more severe cases. But again, this is all mild TBI. These are all the same diagnoses. So for our next piece of research that we really want to focus on will be to classify by type, like diagnostic, rehab, mental health, to kind of break it down like we did for the pharmaceuticals. Maybe these classes are different. Maybe if they're getting only recommended treatments, that's what's driving some of these trends. So we're really excited about the future of this research. And with that, I'm going to hand it over to Dr. Drennais to talk about patient care. All right, so now we've looked at this population and looked at all the services that are out there and seen some very different trajectories. Now I'm going to talk a bit about the clinical side and sort of where the rubber meets the road. I've talked to a lot of you over the last couple of days about how these clinical encounters sort of make you feel, what you have access to, what you don't have access to in terms of moving these patients forward. And I'll move, I'll talk about concussion and MTBI interchangeably in my slides. So a little bit about the clinical care. So I have to be cognizant of the fact that we may all be managing these patients at a slightly different time point. In other words, the symptom burden, the treatments we might recommend in our gut, in the emergency department or an acute setting might be very different than the patient in front of you who's six months out and has persistent symptoms and is still not back to work. And so aligning the time course of these injuries and what resources are available at that time can vary from centre to centre. Some of these patients, as Kerry mentioned, may have early intervention and do just fine. An example of that would be in Ontario, where I work, a patient may have a concussion, see their primary care doc, and immediately they're administered sort of an MTBI point of care program is what they call it in Ontario. That's where the family physician, once approved by the Workers' Compensation Board, can immediately administer some treatment. It might be physical therapy, chiropractic, some of it's patient choice. And I may never see those patients. In a different setting, maybe there's a few red flags, it escalates a little bit. So that's when we want to get occupational health professionals involved with that functional occupational lens. And they may then be entitled to a few more services with that anchor back to work if they look like they're going to be out of work for too much longer. Furthermore, to take the most complex of the complex, which is what I see in one of my many clinics, these are folks that have symptoms well beyond three months, well beyond six months sometimes, persistent symptoms, sometimes they're completely out of work, they either have a complex symptom burden or a complex job, and then it's our job to go down the road of multidisciplinary care. The reason I say this is that we're talking about what services, what investigations are warranted, and I think the research will show in the future what are the top and most high yield interventions early on in the concussion population. We have some epidemiology to suggest that those with preexisting mental health history, we know they have prolonged recover, we know they have a higher symptom burden. So what else can we glean from the research to suggest who needs what treatment and at what time? and that will help deploy some resources which we know are scarce between jurisdictions. So finally, this is probably a research project on its own, but I thought about this recently is the vast majority of your patients, when you see them maybe weeks out, almost all of them will have been seen in an emergency department, acute care setting, maybe their primary care doc before they get to somebody with occupational health expertise that can help with the return to work process. And with the persistent symptoms, many of my patients will go back to the emergency department multiple times for things like headache and imbalance and dizziness. So following these patients through the system is sometimes not linear and really impacts what we recommend at that point in time. So I'm going to walk through a couple cases and I want everyone to sort of think to themselves how they feel when they hear this case and how they feel when they hear case two. What does it do in your diagnostic or clinical brain to suggest what this patient might need and what you think of their symptom burden? So this is a 28-year-old gentleman who had a complicated mild TBI after a fall from height. He had a nondisplaced skull fracture, mild, very mild epidural hematoma and cervical strain and associated headache. He was fortunate, he bypassed the rest of the system and sort of came right into my clinic where we were doing multidisciplinary complex care. But I worked with an occupational therapist in these clinics and the first thing he said was I'm fine and I'm ready to return to work. So no show of hands, but think to yourself, would you send this person back to work right away, four to six weeks out from this injury, and why? Most of us would love it if a patient came to the door and was ready to return to work with little to no intervention. So this is the case of, I guess, an occupational medicine physician knowing when to put the brakes on a little bit such that there's a sustained and safe return to work. So is he safe to return to work, let alone ready? So he had a skull fracture. Going back to my neurosurgical training, I would want a skull fracture healed well beyond four to six weeks before I put a guy back on scaffolding. His marijuana intake increased from two to seven grams a day, so what's going on here is it's self-medication. We screened him for his mood. He clearly had some mood disturbance, he was struggling, had some passive suicidal ideation. And his occupational functional demands were quite high. He has a heavy PDC level and he works at heights. And I also learned that he wasn't wearing a fall arrest or a hard helmet at the time of his injury. So I put the brakes on this a little bit, took a step back, agreed to see him again in follow-up. He engaged fully in a multidisciplinary pre-approved rehabilitation program through the Workers' Compensation Board. And through this program, I can access PT, kinesiology, OT. He had some psychological help as well along with his rehab. And immediately if I need any other consultants, ENT, psychiatry, it's already pre-approved. So in other words, whatever I need, I'm sort of the quarterback of this case, I can access this. So when we got him into rehab, he required some balance retraining and we simulated the work and in my spidey sense, I guess was right because he panicked the first few days we had him up on a beam trying to see if he felt safe due to his head injury. He had some vertigo. Significant education around safety at work, his symptom burden. We managed his headaches. We can take this offline, but I manage over 95% of my post-concussive headaches with nothing more than magnesium, acetaminophen, and NSAIDs. I've never prescribed anything for these cases and they get better. And he had a successful return to work. So case two. Think about that young guy. Whole life ahead of him. Made a good recovery and he was sustained at his job in construction as well. Case two. 64-year-old female education worker supervising the gymnasium at lunchtime and got hit in the side of the head with a soccer ball. Immediately reported she felt her legs were wobbling, she tried to stay steady, she was stunned, she collapsed to the ground. Her coworkers came, scooped her up, I think they sent an ambulance for her. Developed a constellation of symptoms consistent with concussion and cervical strain and possible mood disturbance. So this is how they came into my clinic with this label. So just think to yourself, how many of you in this room think that a concussion can be caused by a soccer ball, right? How does that make you feel now compared to the first case, right? So there may be like 20% of hands going up, right? I asked the same question to a bunch of medical advisors at multiple boards in Canada and the jaws just dropped, okay? Doesn't matter what you think. They look the same. They're in your clinic. They've already been labeled with a concussion and it's our job to sort out the key issues that are untreated to move these patients forward. So we can have a debate about causality and impact to the brain and all of that, but from an administrative standpoint, this is what comes into clinic. This patient has been dealing with this concussion for months by the time they get to me sometimes. So a number of barriers were highlighted here. The big one was mental health and mood. She reported to us low mood. She measured with at least moderate mood disturbance in the PHQ-9, GAD-7 was up there as well, and she had clinical features in the clinic, flat affect, tearful, so on and so forth. On top of all this, she was just recovering from a prior compensable injury on her shoulder, rotator cuff repair, and hadn't really started physical therapy for that at the time of her concussion, and she had no targeted management for these concussive symptoms to try to understand why she's completely out of work a couple months later. So this is where I lead into a little bit of the evidence. So the Ontario Neurotrauma Foundation has a really nice guideline on concussion and MTBI. They even have a small section in there on return to work, and this is sort of my mantra with regards to concussion. These patients all come in, and when you do your review of systems, they have about 18, 20 symptoms. We do symptom inventories with them. That's pretty par for the course if somebody's been dealing with a concussion symptom for a while. But we as clinicians can really identify and manage about four of them. What do I mean by that? So the evidence suggests that we need to screen and identify depressive or anxiety-based symptoms early and up front. Some people may have this problem, some may not. Furthermore, we'll know in the history whether they have pre-existing problems. Sleep disturbance is common after MTBI, and post-traumatic headache. I see this all the time. And then the third symptom, the fourth symptom that I see a lot of would be reports. Again, this is subjective reports of imbalance, dizziness, vertigo. I examine these patients closely. Occasionally, I'll pick up on a neuro-otological disturbance or a BPPV or something along those lines. But oftentimes, it's nonspecific, it's cervicogenic, and it responds well to physical therapy. The last three, which are probably the most major concerns from my patients, is cognitive impairment, fatigue, tinnitus, noise intolerance. It's like their brain is totally sensitized, everything around them. Often that links back to the top three columns, the top three points here. And so we know in the diagnostic criteria for anxiety and depression, you can get cognitive symptoms, you can get sleep impairment. And so in my experience, and the evidence would bear this out, if you treat the anxiety or treat the depression, if it's present, these other symptoms sort of fade away and fall in line. So her clinical course, we had access to psychiatry, she was agreeable to medication, she also had some psychology support, managed her mood, she made excellent improvements. She engaged in rehabilitation. When I first saw her, it wasn't even appropriate for rehabilitation, given the mood concerns. And she reduced her symptom burden, which we log over time as we follow them all the way back to return to work, her function changed, and we put forward return to work recommendations as well. So that would be the other complicating factor that I see in concussion, is sometimes people are doing well in the rehab, but it's not necessarily anchored back to their graduated return to work plans. Finally, you know, she had permanent restrictions from her shoulder surgery, and so, but really what the ultimate blockade or barrier for her return to work were these other symptoms related to the concussion that she had. And so we knocked those down, and she had a good outcome. So you'll notice there's a bit of a theme, knowing, you know, respecting the fact that I tend to see these complicated cases a lot of the time. Mental health, and I've heard it a few times throughout the conference, and access to resources for mental health within the workers' compensation system can vary from state to state, from province to province, and country to country. So when I first started doing these clinics, oftentimes I would say this is a very clear change in this individual's mood since the injury. They have a clinical presentation that's consistent with this. Sometimes they would get declined, sometimes they'd get denied if I was trying to get them psychiatry or psychology or what have it. So this is a paper that was in JOEM last summer, kind of an interesting study design, all on workers' compensation data, and in that paper they discussed some of the pathways that I've alluded to earlier. But the Kohl's notes of this are that they looked at early mental health intervention on these claims, and all claimants, they had 17% of them that received a mental health intervention, and then they sort of did the analysis on those who received it in the first 90 days or much longer. And lo and behold, the folks with early intervention had lower costs and shorter disability duration. This is a little bit counter to their hypothesis. They sort of talk about this in their discussion that they thought that people who were offered mental health supports earlier in their claim maybe had worse psychological symptoms or more psychopathology, and therefore they may be longer out of work, but lo and behold it actually reduces time. And so again, this means that we need more research on who to target early and how hard and how aggressive right up front in some of these cases, because this is such a burden, particularly in the concussion world. And on the top right here, I just want to highlight in this red box, I'm kind of wearing my physical medicine hat here, but as we all know, it's important to understand the pre-injury history. So we know bad prognostic factors in concussion, whether they're athletes, whether they're workers, are things like pre-existing ADD, depression, anxiety, prior head injuries. And if we know that already, it stands to reason that we can help them earlier and identify those folks who are maybe having an exacerbation of that component of their injury. It makes complete sense. And then finally, the sort of the neuroscience, the interrelationship between sleep, pain, mood, cognition, it's undeniable, it's there, but when we list a laundry list of symptoms in the concussion world, it's very hard to tease between them if you haven't done it in a while. And so my job in these patients is to target which things that I can, and then follow them along, and undoubtedly, sometimes we target pain, which is headache for the most part in concussion, mood, and all the cognitive symptoms sort of fade away. There's some nice literature in the neuropsychology research too that suggests that patients living with concussion can have symptom misattribution, and the example I would give would be the patient with high anxiety or adjustment disorder may say they can't remember, they can't concentrate, when in actuality, it's the anxiety causing it, not the MTBI or the concussion itself. And this is a concern to patients, I probably get asked once a month whether they're going to be destined for CTE, early dementia, all of these things, and I also have data on them because we test their cognition in the clinic, and so we can say to them, look, I know this is the symptom you're reporting, but you actually test very well. So, to summarize some of the clinical work, identify key treatable symptoms early and up front, because that's what we can treat as medical doctors. For each of those things, whether it's BPPV, post-concussive headache, mood disturbance, we can treat them all in an evidence-based fashion, that's what I do every day. Target these symptoms, because they are barriers for return to work. Some patients will say to me, I said, if I could take away just one symptom, they would say, if I could just get my headaches under control, I could go into the office. If I could just get my dizziness under control, I can go back to working at heights. And so what we do is we navigate some of these symptoms as the patients report them to us, and we knock those barriers down. So they can't say they can't do anything, because we're running along beside them with with these rehabilitation goals and plans. Finally, I tell all my patients that long-term neurological impairments, I don't want to say they don't exist, but they're exceedingly rare. So I would love to know, if I show a hand, when's the last time you examined someone, say a month after a concussion, who had an abnormal neurologic exam? Right? Exam's always normal, almost always normal, right? And so that's reassuring for patients, and it just goes to show there's other factors that are driving the symptom burden. And these persistent constellation symptoms are often untreated targets for intervention. So when I first started doing the complex clinics, I had people out of work eight months, a year, and it was simple. They were depressed. They'd never had any treatment. They never had any rehab. And so we did that, and some of them would be back to work within a span of six or eight weeks. So just because someone hasn't had treatment doesn't mean we shouldn't give up on them. And just identifying these symptoms and wading through the complexity is sometimes something very practical. And finally, don't forget about mental health. I've cited another paper here. Not only are these folks with pre-existing susceptible to the sequelae of concussion, but it really is emerging in some of the other literature and guidelines to just screen for it and make sure it is observed and managed if it is needed. So now we've talked a bit about some of the pain points in the clinical world of managing these patients. I'm going to hand it over to Dr. Jolivet here to talk about how we support these patients in return to work. Thank you. Am I, can you hear me? Is my mic working yet? Yes? Yes? No? OK. So, hi, I'm Dr. Jolivet. I get to talk about sort of the fun part about this, which is how we get people back to work. So I work for a disability insurance vendor. You still can't hear me? OK. How about, is this better? You might turn off this then. So I work for a disability insurance vendor. We focus very strongly on stay at work, return to work, and one of the main points I'm hoping to convey here is return to work is not only possible for people with concussions and mild TBI, it's really the expected outcome, and you want, we want, on the disability side, we want people to be able to get back to work. On the disability side, we want to convey to people right from the beginning that these are not career-ending injuries, generally. These are injuries that people recover from. They go back to work. We try, in the program I work in, we try to get people connected with a consultant who's an occupational therapist or an ergonomist or a nurse. We try to get people connected with someone within two days of us getting a claim when someone's gone out on work, or if someone is at work, you know, oftentimes people develop or have an injury, they go back to work, and they start developing problems there. When we hear about those people, we, again, we try to get in contact with them within about two days, within two business days of the referral, because we see and have very clear evidence that earlier intervention makes a tremendous difference. And on the disability side, we're always talking about limitations and restrictions, and you probably know capacity, limitations, risk, and restrictions. We tend to think of limitations as being things people don't do as well because of a medical condition, restrictions, we generally lump risk and restrictions together, things they should not or cannot do. But one of the things that's really crucial for us is we, on the disability side, are addressing limitations and restrictions. And it really doesn't matter what the ideology is. It doesn't matter whether someone has cognitive impairment from a stroke or from mild TBI. When people are struggling, it's more what's the impact on their job? And when we look at the impact TBI has on the workplace, we see three areas. One is the physical symptoms. People have things like muscle weakness, difficult to coordinating. You mentioned someone who needed balance retraining. So physical symptoms. Second, we see problems with thinking and learning. And third, changes in motor skills, hearing, vision, emotions, or mood, and their behavior. So across the board, really, these injuries can lead to almost any kind of limitation or restriction. As you gather from the prior part, headaches are the largest issue that we see within the disability arena. So about 71% of people will report headaches within the first year. It declines over time. But at the one year or three months after injury, it's about 18%. So still quite significant. There are, however, many accommodations we see for headaches. And within the disability sphere, we hear people have headaches all the time. Some of the things that really are helpful, like often with people with migraines, we'll work with them to change their lighting, to get them lighting that doesn't trigger migraines. We also will give people therapeutic glasses, lenses that filter out light that can trigger headaches. We also do a lot of noise mitigation strategies. Things like noise cancellation headsets, putting a sound baffle on their cubicle, having an ear, you know, if someone's needing ear protection. All of those things, if you can stop noises from impacting the person, that can help stop headaches being triggered. Probably the most common thing we see, though, most common accommodation we see for headaches are modified break schedules. So when a person starts experiencing the first signs of a headache, they're able to go take a time, go to a private area and do, you know, whether it's taking medication, meditating, doing what their treating provider has recommended in order to reduce the likelihood that they're going to have a full-blown headache. So cognitive challenges, again, we see this not just with TBI and concussions, but all sorts of different people come in, you know, post-stroke, things like that. And obviously, if you're having trouble thinking, that can have a profound impact on your ability to work. And one of the things that, from the disability perspective, we really focus on is that the accommodations, the way you help people, are not generally intuitive. I'm a psychotherapist or have been a psychotherapist for decades. It wasn't until I started working in the disability arena that I started learning that there are ways to accommodate things like anxiety, depression, addiction. That's not something, at least on the provider side of the equation, I was ever aware of. And people don't recognize that there are accommodation strategies available to help with things like cognitive impairments. The most common things we do are organizational tools, things like planners, calendars. We do a lot of task separation. If someone has to do a process that requires 10 steps, map those out and separate the tasks so that people aren't trying to multitask. Because, one, people in general don't do multitasking well, despite what we think. And two, people with cognitive impairment are particularly poor at multitasking. So break out the tasks, give people workflows, give people written instructions, give them guidance to help them do all the steps. I mentioned monotasking. And then written instructions. One of the things we often recommend is the supervisor, instead of telling an employee, you know, I want you to do this, this, and this, to always, always write it down to provide written feedback. And, of course, the accommodations depend on the specific limitations and restrictions. I'm mindful, I mentioned to my co-presenters that the senator here in Pennsylvania, Fetterman, had a stroke and he has, I believe it's an auditory processing deficit, which makes it very difficult for him to hear, to understand language that he hears. He's got an accommodation. He can read perfectly fine. He's cognitively intact. It's just when audit, when he's processing auditory information, that's slow and unreliable for him. So he has someone who does a closed captioning wherever he is. And I know there was a big fuss because during one of the debates, his closed captioning machine malfunctioned. And without it, he really struggles. But with that closed captioning, he's able to, you know, function essentially normally. So psychiatric complications, again, very common. Most common is major depression. And you know, it makes sense in that you're dealing with new limitations. Oftentimes your sense of self has been impacted. As we know, we tend to think of ourselves as our minds. We tend to think of ourselves as sort of intellectual beings. And when that's impaired, that can be really difficult. So you know, obviously we want people to get the appropriate treatment in order to address depression. But from a disability insurer's perspective, we can also help employers accommodate people with things like bringing a service animal to work, or even having a support person, a person who you work with who can be there to sort of, when you're struggling or when you're feeling like you're overwhelmed, you can talk to that person. The most common accommodation we see is flexible work scheduling. We've talked before about sleep disturbance. People with sleep disturbance generally are not good in the morning. So we'll work with people to negotiate a late start time or a flexible start time. We also often work with people to give modified break schedules so people can take time out to address issues as they come up. And you want to utilize positive feedback as a management strategy. Criticizing people who are depressed is not an effective way to get them to perform better. So the most common accommodation we see, and I looked at, you know, all of the, not just concussion, but also TBI, closed injury. Most common accommodation we see is a gradual return to work, usually going from full to part time over the course of months. Second most common is limited duty, someone returning to work but not being responsible for all of their usual duties, instead having some duties that they're not responsible for, at least early on. And sometimes they may not be able to continue, they may not be able to go back to all the essential job functions of the position they held. So you might add on other duties to, you know, fill up their time. We also do see ergonomic equipment, but it's difficult when we're involved oftentimes, almost all of the time we're seeing, well, almost all of the time, roughly half of the time we'll see people with comorbidities, especially musculoskeletal. So it's hard for me to tease out, you know, how often are we giving ergonomic equipment because of a musculoskeletal condition? How often is it because of the brain injury? So the takeaway, before we open it up for questions here for me, is as a disability insurer, I'm always pleading with employers and treating providers to say, we're here to support you. And although I know I have friends who, when I started working insurance, said I had gone over to the dark side. But the reality is the goal for a disability insurer is really the same as the goal for the treating physician, which is to get people back functional. We want people working, not just because we want to save, you know, money on claims. We want people working because that's really a crucial part of a full and meaningful life. The people, they develop meaning out of the work they do. They find fulfillment. It's a social role that can impact their relationships, their families. There's a whole plethora of reasons why people should work, and we're on the same team when it comes to that. And the other thing I would, you know, encourage you to reach out, you know, if you're working with patients who are struggling, reach out to the, you know, if they have a disability insurer. I'm sure the disability insurer is reaching out to you for paperwork, which I know, as a provider myself, can be annoying. But you can also reach out to the disability insurer, the workers' comp insurer, if there are other entities involved to get people moving forward. One of the things that's really, I was struck with Dr. Gernay's statement, and when he and I talk, it's always, how do we keep the person moving forward? You know, we target the next symptom. We target what's, you know, preventing them from moving forward. But it's, sort of comes from a place of recognizing these are people who can and will recover. They can and will return to work. They can and will live full lives. We just need to always be looking to the next step. How do we help them? And that's really, you know, for me, the most crucial thing, that we want to get these people back to their ordinary lives as much as possible. And with that, I guess I will open it up for questions. And if you don't ask questions, we will tell, I will tell jokes. So, and they're bad. Thank you. Is that coming through? There we go. Thank you. Thanks for the great talk, but thank you to all three of you. Just a question that I don't think was addressed is, I always have the concern of secondary head trauma, particularly while people are still symptomatic. I just wondered if you all could comment on what you've seen as it relates to that, sort of mitigating that risk of secondary head trauma when they return to work. I think that's you. I mean, the, I guess what you're probably alluding to is the secondary impact syndrome that sometimes we've seen in football players who, oh, sure, am I there now? Okay, good. Yeah, I think what you're referring to is probably the second impact syndrome that sometimes you see in football where you get two brain injuries sort of back to back and can theoretically kill you. Usually these are so spread out that it's unlikely. And then I would also suggest that, you know, if you look back at my first case, that would probably be a reason why I kept him out of work a bit longer so he can fully heal and recover. But I would say, generally speaking, it's low risk. And I would also ask myself, what type of work are they in? You know, are they a phys ed teacher, or are they a PSW, or, you know, a nursing worker? Or are they a construction worker who's fallen already eight times in the last two years? So hopefully that answers your question. I think it's on. There it is. Hello? Thank you very much for an excellent presentation. My question and comments relate to the cohort and data set of patients that came from California. Just a couple of comments. The first question was directed at whether you saw an inflection point in the data set related to the implementation of the Traumatic Brain Injury Guideline. The guideline was actually published in 2017, late 2017. California adopted... Thank you. California adopted the guideline in late 2018. So it would be fair to say that probably none of those patients were treated according to the guideline, or at least the ACOM guideline. There may have been an alternative guideline that was used, but it wasn't the ACOM guideline. The other thing on the issue of return to work, you showed a very wide variance in terms of return to work following mild TBI. Care in California is quite disparate. Only about 20% of injured workers are treated by an occupational medicine provider. That means that 80% are going to a family practitioner, they're going to an internist who may not know about the ACOM guidelines. And then the other thing is a lot of your patients were from retail, which means they work at Chez Targer, and low wage, relatively low wage, low locus of control. They're getting two-thirds of their pay if they're on disability. Why go back? Yeah, great points. A lot of those, yeah, especially the retrospective review of the ACOM guidelines, because you're right, those were written in 2017. So we're just using that as a baseline, but I think that's a great point. And yeah, there's no guarantee, even if, you know, the state of California has been great with adopting the ACOM guidelines, but yeah, use of them, and you know, it's a recommendation. I think there's more in recent years of doing more incentive to use that, but I really like your idea that point that PCPs and family practitioners aren't even aware of some of these guidelines. And like what Dr. Drené said, a lot of people are being seen in EDs and internal care, and by the time they get to OCMED, like it's a little bit further on. So those are very interesting. And yeah, I agree with you with the retail. I thought that was really surprising in our group, but I know we've seen in the news lately, you know, retail workers are, especially during the pandemic, they're getting punched in the face at work. I wouldn't want to go back to that either. Like I totally get that. So I'm interested to see also how this cohort plays out over the pandemic to see what those look like. So great points. So amazing talk on such a common topic. Sorry, I'm still a little short of breath from Roseport, but two quick questions for you guys. One, I thought I heard kind of opposite views on NSAIDs and magnesium. And then two, I'm not a neurosurgeon, but I thought if you have a skull fracture that puts you in the moderate or severe, I don't know. I'm not an expert on TBI. So just around the TBI. So again, if we're looking at GCS, if we're looking at LOC, there's about six, seven different ways to classify severity of TBI. You'll notice I said complicated MTBI, and that's actually a subdivision of the American College of Rehab Medicine diagnostic criteria. So that's what that mild diagnosis is based on. With regards to the magnesium and the NSAIDs and the acetaminophen. So the guidelines would suggest there's, I believe there's no recommendation for it. The other thing that I thought about is that the guidelines, if I recall, are all TBIs in general. So certainly if they're more moderate or severe, they may be given NSAIDs in a critical environment, but also most emergency docs that I get patients from, when patients come in and they have a terrible headache and neck pain, that's the easiest thing to give them right there and then. Now, just because there's no recommendation doesn't mean, well, in this setting there isn't a recommendation. It is part of the guidelines that I subscribe to, and the thing you just have to be concerned about is rebound headache, and so I would limit that to less than 10 days out of a month. Yeah. Sound good? Okay. Yeah. Just real quick, I was asked to monitor questions coming from the streaming audience. I have like seven or eight. So rather than take time away from these guys, I'll just ask the presenters to go online afterwards and answer those questions online. Thank you. I just have a quick question about the cognitive testing. You referred to the fact that you're able to cognitively test your patients in clinic. I'm wondering what strategies or tools that you use, and are they accessible to those of us who are in private practice? Sure. So sometimes it's as simple as a Montreal cognitive assessment. The occupational therapist will do this in advance. We also do in our bands, and then they have some elevated testing that they can do. So if the individual is a construction worker, they have like a doll chair test. They get them to put together an Ikea chair and different various things, but they do have a battery of cognitive and psychological tests that they do, and they monitor it serially over time. So our bands and MoCA would probably be the big two. Okay. We might do trails and some other higher level stuff if there are drivers. Right. I was wondering if there's something more special. Yeah. Thanks. Thank you for the excellent presentation. One thing I found with traumatic brain injury patients in the acute phase, they're returning to work, is insomnia in addition to depression. And there's been some really interesting research coming out in other societies about cognitive behavioral therapy as an adjuvant of treatment. I was wondering just with the panel if you can comment on insomnia in general, the treatment for that for the patients. And then to piggyback on that cognitive behavioral therapy, is that something that at this point would be recommended in certain circumstances? Sure. So I think what you're talking about, CBTI, cognitive behavioral therapy for insomnia, is very strongly recommended. It's currently considered the gold standard for people who have insomnia. And cognitive behavioral therapy is generally considered one of the most effective evidence based treatments for people with traumatic brain injury, regardless of whether it's mild or severe. Particularly though, I think we've seen more people utilizing dialectical behavior therapy, which combines the cognitive behavioral therapy, which is essentially identifying thought patterns or beliefs that are self-defeating or not based in reality, so to speak. But combining that with mindful meditation. And the mindful meditation has been shown really to be beneficial for people, helping them control their impulses, helping them to pause and consider actions. It's also been shown to be very effective in helping people manage their affect, making sure that they're not being too aggressive or getting angry or irritable too easily. So dialectical behavior therapy, I know I have a friend who works for the military. And he does a ton of dialectical behavior therapy with people with blast injuries, people who've had IEDs explode. So yeah, CBTI, CBT, and dialectical behavior therapy are really very helpful in all of these areas. Thank you. Sure. And we're over time. Question. Can you just comment briefly on the role of imaging studies in patients with mild TBI, particularly before sending them to cognitive behavioral therapy, like has ongoing headache. Would you do an imaging study and send them to cognitive behavioral therapy or something? So acutely, there's CT rules, like an emergency setting is a mechanism consistent with something that needs urgent imaging. Longer term, I almost never get an MRI for a couple reasons. I correlate it with the mechanism of injury, my neurologic exam, and I go from there. Occasionally, I've had a couple conversion disorders that appeared to be almost like a stroke, and the patient had risk factors. So I got an MRI to rule that out. But I rarely image for them the basis of headache. So I have a background in sports medicine with a fellowship, so I follow their guidelines a lot. What is the role for ACOM in their guidelines with SCAT 5s, use of the Sway app, or other those tests to kind of monitor symptoms? Yeah, so I get asked this at so many different boards coming from the sports med background. The SCAT's constantly evolving. Some would say it's more of an acute type of symptom inventory, if you will. It hasn't necessarily been validated in workers, which is why there's not more of a move on that. About 10 years ago, they would use that, because that's sort of all they had. But we tend not to try to treat athletes and workers identical for a lot of different reasons. But the SCAT is not something commonly used in my clinics or in any other workers' compensation boards that I'm working with. But to your point, I've thought about that as well. It's important. Thank you all. Thank you. Applause

mild traumatic brain injury

TBI

workplace

returning to work

worker compensation data

head injury-related claims

symptoms management

multidisciplinary approach

cognitive limitations

research