Good afternoon, and welcome to today's webinar, Managing Concussion and Post-Concussion Syndrome in an OEM Environment. My name is Heather Hodge, and I'm with the American College of Occupational and Environmental Medicine. There are two features available to communicate with the panelists and other attendees. You may post general messages in the chat feature. Messages can be shared with either the panelists or all participants. Use the dropdown box to select who you want to share your message with. Go ahead and give it a try by introducing yourselves to all panelists and attendees. Let us know your role and where you are from. Questions, on the other hand, should be submitted in the Q&A box. Panelists are monitoring this box for questions, so please be sure to post all questions here and not in the chat box. If you are not familiar with ACOM, we are a membership organization that promotes the health and safety of workers, workplaces, and environments through education, research, development of public policy, and advancing the field of occupational health. Before we get started, just a reminder that we are recording today's session, and we'll email the link of the recording to all registrants. We are delighted to have Dr. Steve Wiesner and Dr. Daniela Goff with us as faculty today. Dr. Wiesner worked for the Permanente Medical Group from April 1994 through May 2020, at which time he retired. During that period, he was the Kaiser Permanente on-the-job medical director for workers' compensation services and served as the medical director for the healthcare organization providing oversight for utilization review and case management services. Dr. Wiesner was the physician advisor for the Kaiser Permanente National Integrated Disability Management Program, supporting the eight Kaiser Permanente regions, providing disability management education and resources. He now serves as a medical advisor for PureWell and Karuna Labs, and is a consultant with the Colorado Permanente Medical Group, supporting their disability management program. Dr. Wiesner obtained his medical degree from the University of Wisconsin and completed his residency in physical medicine and rehabilitation from Northwestern University Medical School, the Rehabilitation Institute of Chicago. Dr. LeGoff is one of Acela's Behavioral Health's Clinical Quality Assurance Advisors. He is a licensed neuropsychologist with more than 25 years of clinical experience, having held many prestigious clinical and teaching positions at universities and government and healthcare institutions nationwide. Dr. LeGoff was embedded as a neuropsychologist at a rehabilitation program at a large workers' compensation organization. A world-renowned speaker, author, and expert in personal development and cognitive behavioral therapy, Dr. LeGoff has conducted professional training worldwide. We are so glad you're both able to join us today, and we're looking forward to another fantastic webinar. I'll turn it over to you now, Dr. Wiesner. Heather, thank you very much for that kind introduction. What we'd like to do to start off is briefly go through what the objectives, what our goals are for the presentation today. And as Dan is the content expert, I will basically serve as the moderator asking some questions, but I really want to make sure that Dr. LeGoff has sufficient time to cover this important information, which actually could be like a full week seminar, but we'll try to hit the highlights over the next hour and a half, clearly leaving time for questions and answers. Before I jump into the outline, I just want to acknowledge, again, that neither Dan or myself have any conflicts of interest, and also acknowledge the permission from Reed Group, which provides the ACOM Practice Guidelines through their MD Guidelines website. So we'll also send out after the presentation, the PDF, which identifies where much of this information comes from, and that is the ACOM Practice Guidelines Chapter 17, which was updated in October of 2018. So again, a call out on a thank you to the MD Guidelines Reed Group people. So these are some of the content areas that we would like to discuss today, basically identifying the differences between concussion and or mild traumatic brain injury, and the subsequent consequences of post-concussional syndrome. Dan will cover some of the initial care and management of these presentations. We're going to focus primarily on mild TBI. We won't be covering too much information on moderate or severe traumatic brain injuries. And then Dan will also identify the importance of psychoeducation and support. As we all know, identifying risk factors early in any patient's presentation is critical for successful outcomes. And we'll talk about identifying what these important risk factors may be. I'll cover some of the important areas that the occupational health primary treating physician may encounter, including the timing of both further assessments and ultimate consideration for possible referrals. And then we'll also talk about generally activity, return to activity and return to work decision-making. And then Dan will close based on a model that he's most familiar with. And most critically, because we like to focus on the importance of evidence-based medicine to guide our practice, Dan will talk about some very hot off the press research that he himself has actually performed. Next slide, please. So Dan, let me turn it over to you to talk about the differences between concussion and post-concussional syndrome. Yes, Steve, thank you very much. So obviously the most important difference between mild brain injury and or concussion and then post-concussional syndrome is that concussion or MTBI is a medical diagnosis based on the exertion of physical force or deceleration injury to the brain. And post-concussional syndrome is a psychiatric disorder with the onset essentially coincidental with a concussion. So typically people get a concussion and then they don't get better. And that set of diagnostic criteria we will go over, but the main idea is that it's a prolonged or delayed recovery from a concussion with an overlay of psychiatric symptoms. So for mild traumatic brain injury, obviously you're gonna have some confusion, disorientation or alteration in mental status that follows within 30 minutes of an incident involving trauma to the head or deceleration. And then some focal signs can have seizures or transient intracranial lesions, small intracranial bleeds. A Glasgow coma score of 13 to 15 after 13 minutes would put it in the mild category. And clearly we have to rule out that there's substance abuse or medication side effects or other kinds of illness or injury causing the disorientation. Sometimes you'll see people that have coincidental, transient phenomena like dizziness or loss of consciousness that precipitates a fall. And then you're in a difficult position of trying to tease out what came first. Post-concussion or I mean, concussional symptoms or the dizziness or fainting spell. But this just to be really clear is the medical diagnosis and the post-concussional syndrome is an F code and it's a psychiatric diagnosis. Heather, can you forward us to the next slide, please? These guidelines are from the Ontario Neurotrauma Foundation. They did a really good job of summarizing this. There are also similar summaries from the ACOEM actually, and then a number of other organizations have published studies recently summarizing criteria. They've defined a concussion as an acute neurophysiological event related to blunt impact or other mechanical energy applied to the head, neck, core body, sudden acceleration, deceleration, or rotational forces. The clinical signs are any period of loss or decreased consciousness less than 30 minutes. And that's sort of the cutoff between mild or concussive phenomena and then more serious head injury, loss of consciousness for up to 30 minutes. Post-traumatic amnesia or lack of memory for events before or after the injury. And then alteration of mental state at the time of injury, typically, which would be confusion, disorientation. Physical symptoms include vestibular headache, weakness, imbalance, altered senses, and dizziness. And then no evidence of an intracranial lesion on imaging. I have seen people diagnose concussion in the presence of intracranial bleed, which is technically not correct. So if there is evidence of an actual intracranial bleed, then that is a brain injury, not a concussion. Next slide, please, Heather. So Dan, before you jump in, this is really what we're gonna spend much of the remainder of the presentation on. But as Dan alluded to, post-concussional syndrome is a mental health diagnosis. Dan, you wanna give us an overview and then the rest of the time we'll really do a much deeper dive into this information. Sure, yeah. Unfortunately, this slide got a little bumped around, but you can still kind of follow it. I mean, there are typically differentiable types of symptoms that follow from the concussion. Interestingly enough, there isn't a specific timeline. Now, again, that sort of brings up the fact that one is a physical diagnosis or a medical diagnosis and the other is a psychiatric condition. So there isn't like a continuity between them. So you can have concussion and then sometime later. And so the real trick is deciding when does this seem to not be just the residual effects of the medical problems associated with getting bonked on the head. And this seems to be more of a psychological problem. And that's kind of a gray area because there really isn't a firm cutoff. I think Dr. Wiesner has said before that he uses about a month. That's a pretty good rough guideline. It sort of depends on how people present. One of the little clues that I would say that suggests that you're headed towards post-concussional syndrome from concussion is when you start seeing symptoms being added or expanding range of symptomatology that's being presented as the person comes back for follow-ups. Because as Dr. Wiesner and I both know, concussions usually get better, not worse. And if they're getting worse, that usually means there's the onset of something else is going on. But headache, fatigue, sleep disturbance. Dizziness is one that can really linger a lot. And it's difficult to tell whether that's coming from otolith organ issues, if the impact to the outside of the head affected the inner ear, or sometimes it's vestibular problems because of ocular motor issues. But headache is usually either intracranial changes in vascularization, or it could be myofascial, depending on if there was a direct contact to the skull, sometimes laceration or something, and maybe causing a headache. But they're extracranial symptoms typically. Memory complaints, intolerance of stress, emotion or alcohol. And then quite often you'll also see hypersensitivity to environmental stimuli. Very common report is sensitivity to bright light or loud noise with headaches and sleep disturbance. And then changes in affect, negative affect are also typical. And three or more of those eight symptoms gets you into the category of post-concussional syndrome. Yeah, and thanks so much for setting us up and understanding the difference between concussion and post-concussional syndrome. Let me just quickly do an overview of the prevalence and incidents, especially as it relates to mild traumatic brain injuries. This incident is probably underreported because most cases of TBI are not severe enough that people seek out emergency care or hospital-based related care. So the numbers that I'm gonna present are probably on the lower side. Mild TBI accounts for probably 80 to 90% of all cases of traumatic brain injury if we also include moderate and severe presentations in both the civilian and the military population. So clearly the vast majority of the presentations relate to a mild or a concussion type of mechanism of injury. What is of concern is that up to 80% of individuals either with mild or up to moderate traumatic brain injuries will experience some of the post-concussional symptoms that Dan just alluded to. And again, we'll spend more time doing a deeper dive shortly. And although the majority of presentations may be mild in nature, they're not insignificant. I think mild may be a misnomer because 44% of all costs based on the lifetime of that individual with an MTBI results actually from that mild post-concussion type of presentation. Next slide. So just to set up in a bigger picture, the good news is that most of these cases that we're gonna see in an occupational health environment, most of these symptoms resolve within three to 12 months. And the majority of people with appropriate care, appropriate intervention, and the right diagnosis should really resolve within one to three months. Now, clearly the challenge for us is identifying those people that may have an early delayed recovery type of presentation. And we'll talk about the risk factors to help identify those individuals shortly. Unfortunately, with this presentation, this is where the post-concussional syndrome becomes very relevant, is that some people will experience symptoms for several years, and actually they may not return to their pre-injury functional status. Some of these more common residual complaints can include mood changes, especially depression and anxiety, and residual cognitive impairments, which can include memory challenges, higher executive problem-solving capabilities, and also challenges in expression. This actually can occur in up to 13%. So again, not a tiny number, rather significant in those individuals at one year who have suffered a concussion, mild traumatic brain injury. Next slide, Heather, thank you. So as in any clinical diagnosis, when a patient presents to the occupational health physician, we're thinking from the get-go, how are we going to address and improve this person's capabilities for returning to their pre-injury functional status, including their options for returning to the workforce? And although this list is relevant to post-concussion syndrome, it's not unique to this diagnosis. We know that in general, older workers, people who have associated cervical or extremity injuries along with their MTBI will have a delayed recovery or an increased risk for that. Individuals with prior or poor job instability, lower educational levels, people in high job strains, but with low job satisfaction or low independent locus of control, and those individuals with limited coping strategies and poor social support structure will most likely be in the group that will have a delayed recovery and could very likely develop the post-concussion syndrome. What I always like to remind people of is that the most important question I think in my world, regardless of the diagnosis, is asking the patient when you initially evaluate them, do you, patient, think that you will be returning to your job and your other life activities as a result of this injury? And if the answer is no, that should be an early warning sign to the primary treating physician that further intervention may be required, especially to support the patient from the psychosocial aspect. Next slide. This is from the State of California Medical Treatment Utilization Schedule and also our ACOM practice guidelines. I'm not sure I completely agree with it, but I do understand the importance of what the statement is stating. To me, the real importance is that we cannot ignore the psychosocial issues that may impact the patient to develop this delayed recovery. And if we do ignore those mental health-related components, then it will be expected if they don't get the appropriate treatment and assessment that we're gonna have a poor outcome. I'll just give people just a moment here to quickly review the comments from ACOM. Heather, next slide. And Dan, let me turn it back to you to talk about some of the common symptoms in a bit more detail. Yeah, this is actually from the excellent guidelines published by the Ontario Neurotrauma Foundation, but they divide the symptoms up into physical, behavioral, emotional, and then cognitive. The physical symptoms really vary a lot depending on the mechanism of injury and the intensity of the initial injury. But as you can see there, quite a few of them kind of overlap. But essentially you've got vestibular problems, changes in vision, hearing, and headache and nausea are the primary symptoms. Quite often, those are seen earlier on more intensely. Some of them linger. Headache often lingers. Dizziness in a subset of people is very disabling and can linger on a lot. And something we'll talk a bit more with regard to secondary gain potential issues or some of the more psychiatric problems, people will report vestibular issues because it's a symptom that keeps them out of work, essentially. You can't drive, and there's a lot of occupations which require people not to be dizzy. Behavioral and emotional symptoms, sleepiness or fatigue, lethargy, lack of energy, apathy even, and quite often dovetail with depressed mood. So lethargy and hypersomnia sometimes, usually those remit within a reasonable period of time. But the kind of lingering negativity, depressed mood, and inactivity, which can kind of turn into its own problem when it kind of bleeds into deconditioning. People are inactive for long periods of time, and they're not as active, and they have a hard time getting back up to speed. And then the cognitive symptoms are the ones that we can more easily assess directly. And feeling slowed down, which is sluggishness in processing speed, and motor rate and response speed to questions or to stimuli from the environment. And then irritability and depressed mood, which obviously overlap with some of the emotional symptoms. In fact, irritability is on both of those lists. Anxiety is on both lists. Changes in sleep is on both lists here. I'm not sure about this slide accuracy, actually. But the cognitive symptoms we see most are difficulties with concentration, which can affect memory, difficulty sustaining attention, work focus, and then probably secondary to difficulties with attention, people are often complaining about memory problems. But it's typically not really a problem with memory per se, but working memory or encoding. Heather, next slide. Dan, thanks so much for that overview. Based on the symptom presentation, can you comment on what your recommendations are in identifying appropriate initial care and management? Yeah, well, this is the physician territory before it gets to us. Typically, neuropsychology gets involved after the initial assessment of the concussion. But obviously, you want to rule out intracranial injury. Most of the time, it's fairly clear from the mechanism of injury. And if you've got someone who falls from a height or is hit by a large, heavy object that's fallen a distance or there's other motor vehicle accidents that have a certain amount of speed, you're much more likely to get intracranial injuries. But CT scan is fairly common for people, and there's medical utilization guidelines. And I think there's specific guidelines. Most people have available to them about when to order CT. MRI is fairly unusual in this mild category of injury. But in the immediate time frame after the injury, sometimes see worsening with vomiting or decreased Glasgow coma scores, or the person becomes less responsive and more disoriented. And those could be worrisome signs of intracranial bleeding or other kinds of mechanical injury. One point I was going to make there is that as you're evaluating the person, it's important not to offer too much reassurance before making the person felt heard. And we hear that is a common problem that people will often feel as though the physician was evaluating them but wasn't really taking them too seriously because they didn't really look too concerned and they were being reassuring very quickly. And they don't really feel as though their level of trauma was conveyed. So even though we may not be alarmed by seeing someone with a mild mechanism of injury, it would be important for the person to feel as though they were taken really seriously and that they were given a thorough evaluation at the initial contact. And then collecting measures early on of either through interview, as Dr. Wiesner said, or by having them complete the PHQ or the GAD-7, which collect data on depressive symptoms and anxiety symptoms early on. Because that can really let you know how things might go in the future. Next slide. Thank you, Dan. So this to me, and I learned something. I learned more than something. I learned so much from Dan every time I interact with him. And this is something that was really helpful for me to sort of conceptualize the presentation, especially as it relates around the patient's anxiety and what the clinician should be very much aware of in further evaluation. So Dan, can you spend some time differentiating the extracranial symptoms and what that may mean from a therapeutic perspective from the CNS symptoms? Right. And I think it's important because a lot of people don't know intuitively or haven't had it in their education what are the signs of changes in brain function versus extracranial symptoms. So when someone comes in with a headache, they may think that that means that there was some damage done to their brain. And we try to reassure people by telling them the brain itself doesn't have pain fibers. It is the part of your body that helps you experience pain, but the brain itself does not actually feel pain. So if you're experiencing a headache, it's going to be from outside the skull, myofascial tissue, or the musculature around the skull, as opposed to some kind of ache coming from an injury to the brain itself. The same thing with vascular changes of the intracranial structure. The vascularization of the meninges can cause a lot of pain fibers. Probably the most common, though, of the headaches come from cranial injuries. So the neck strain causes radiating headaches. And so blows to the head or deceleration injuries can cause neck strain, myofascial pain, or vascular headaches. And none of those are actually signs of CNS changes. Heather, I'm starting to interrupt again. Heather, if we could jump back to the previous slide, that would be helpful. There we go. Dan, you want to comment a bit on the CNS-related symptoms as a differentiator? Yeah. So if you do have changes in vision, it can be ocular. But a lot of times, it's also the occipital area of the brain can be, if you have an impact there. And people are reporting sometimes dizziness and nauseous can have to do with the occipital area of the brain. Can have temporary or brief increased cranial pressure. We do know that the higher impact kinds of injuries where there is shifting around of brain tissue, the cortical structure can take quite a bit of jostling. And you do get difficulties with concentration and sustained attention. That can affect new memory formation. So learning and memory and information retention can be affected. Deoxygenation effects can happen from changes in vascularization, which result primarily in executive function changes. So people are having a hard time planning, sometimes impulse control, difficulties with sustained attention. Those are factors that come from dis-executive function or problems with the frontal lobe. And those are the kinds of problems that, if they do linger, do suggest actual neurological changes from a concussive injury. We come across these less often than you would think based on the amount of cases that report it. But occasionally, we do get actual individuals reporting poor concentration and difficulties with executive functioning. Thank you, Dan. Heather, next slide, please. So Dan, this may be one of the most important slides to really help the treating provider in identifying how, shall we say, significant the actual physiologic presentation is versus what the secondary mental health or psychosocial concerns may be. Yeah. I mean, some of the things you'll want to look for is, first of all, was the incident witnessed? If the person reports that the concussion happened and no one else saw it, then it just kind of takes it down a notch in terms of credibility. If they came and saw immediate attention in the emergency department or if they went to their occupational medicine clinic right away as opposed to waiting, that's not a big indicator. But sometimes, you'll see these long delays, like a week or more. And then suddenly, people will go back and report a whole lot of symptoms. That's quite a bit less credible than if the person immediately sought attention. Evidence of extracranial injury is also a very credible sign. So if you see facial contusions or head lacerations consistent with the description of the injury and the person seeking immediate attention and they're brought there by a witness, then you can feel fairly comfortable that this is a credible presentation. Slip and fall, especially if they have injury to their upper extremities or to the facial and cranial area. In motor vehicle accidents, you'll see that they have seat belt signs or airbag injuries, the red eyes and burned skin from the airbags being deployed. Those are quite credible kinds of presentations. Motor vehicle accidents over about 40 miles an hour with a short stopping time. Someone's getting into a head-on collision or something, 35, 40 miles an hour, pretty much sure that that's going to be a concussive type of injury. And then falling from a height, certainly more than a few feet in the air, and then with the head hitting the ground. Or if there's a heavy solid object striking them that's falling from a distance. Those are all very credible presentations. People who have no physical signs of injury, if they bump their head while they were walking or just moving around in a chair or seat, they bend over and they bump their head or they stand up and bump their head. The head's moving at very slow speed if you're just moving on your own, so a couple of miles an hour at the most. And the deceleration injury from that is not really likely to cause a concussion, even though the injury might be very painful if you walk into something really hard, like a steel beam or something, or you hit something wood with your head, it really hurts a lot. But it's not as likely to cause a concussion. Also, some of the reports of symptoms where people have severe memory loss or loss of long-term memory. We also have people that report very extreme versions of photophobia or hyperacusis, where there's, oh, they can't tolerate the sound in your office or they can't tolerate the bright lights just from indoor lighting. It makes no sense. We see these people all the time that they drive to become, they drive to the evaluation and then they can't look at a computer screen. Well, the outside light that they just came through is 10,000 times as bright as the computer screen that they're not able to look at now. So it's just some aspects of it just don't really hold together. Dan, thanks for those critical pearls of wisdom. Heather, next slide, please. Then you wanna jump into what some of those early risk factors may be, especially from what the primary treating clinician should be aware of. Right, and it's very consistent across the review studies and some large clinical trials that have been published in the last 10 years or so that people who present with symptoms and then at the subsequent visits are appearing to get worse especially if they're reporting symptoms that are essentially either alphabetical or in exactly the same order as they are in the ICD-10. You get the feeling that they're kind of listing symptoms that they've read about as opposed to these other problems that they're presenting with, especially if it's not just a prolonged version of what they were presented with the first time they came in, but there's additional symptoms, especially some of the less credible ones like photophobia, tinnitus, headaches, dizziness that might be added on to an initial headache. Suddenly they're saying, oh, now I can't sleep or they start adding in PTSD-like symptoms even though there wasn't really a criterion A type of PTSD presentation. It wasn't a trauma, that person fell down or they bumped their head and now they're presenting with a lot of emotional symptoms. Now, the more worrisome signs would be if they have a history of previous concussion. That makes it seem a little more legitimate if they've had a history, but if they've had a history of diagnosis of post-concussion syndrome, then you kind of know that this is more likely to turn psychiatric on you. Some of the complaints will be fairly dramatically not credible, which is especially loss of important aspects of memory. Like people will say they can't remember their date of birth, they can't remember the name, they don't remember what happened during the injury at all, even though it was a mild episode or they're inconsistent about what they remember and don't remember. Another kind of warning sign is if they really present with a lot of anger or resentment about the injury or towards people that were involved in the injury, whether it was their employer or a coworker or someone was responsible for them and they're very angry and upset. That can lead to problems because workers' compensation is a no-fault solution, not tort litigation so people don't get reimbursed for pain and suffering. And some people feel that's not really fair and they feel resentful about the fact that this was a really painful and upsetting experience for them. And they wanna make sure that that message comes across. And so they'll really kind of emphasize the extent to which their symptoms were painful and they'll prolong them sometimes, just because of a kind of lingering resentment or negative mood about the whole experience. We get a lot of non-credible mechanisms of injury where people have light, small objects fall and hit them or they bump their head on a movable object like a lamp or a door, swinging bathroom doors. They bump people on the head and then they present without a contusion or anything. There's no physical symptoms and yet they'll report very dramatic post-concussive symptoms and then they'll have those symptoms weeks later. That kind of thing comes up quite a bit. Then you wanna comment on the last point, which actually may be very relevant to the primary treating physician and clinician. Right, it's not uncommon for people to use the worker's compensation system, kind of strategically to get like vacations or, I mean, I don't wanna make people think this is extremely common, but it is a fairly common element within post-concussive phenomena that people are using their worker's comp system strategically as opposed to just to cover their medical expenses. And so if they have a history of filing claims for somewhat nebulous injuries or for when there's delayed recovery from previous injuries, it seems to describe a pattern. And this becomes very clear when you see post-concussive symptoms that someone comes in with a mild mechanism of injury, they don't get better, but they get worse. And then it goes on for weeks. Those kinds of clients often need to be referred to mental health where we can do validity testing. And that's one of the things that a lot of providers miss when we offer to do neuropsychological screening assessments is that we're not just adding a sort of additional layer of assessment, but it's a really good opportunity to find an exit for fairly non-credible cases is through doing validity testing. And Dan, we're definitely gonna come back to that shortly, which I think is absolutely essential to help the treating clinician provide the appropriate and highest quality of evidence-based care under the World Comp system. There may be other issues that need to be addressed from a mental health perspective. They may not need to be addressed under the World Comp claim itself, but we'll revisit that shortly. Heather, next slide, please. So just sort of summarizing a little bit of what Dan just went through, and that has to deal with how can that primary treating clinician really set the stage for a successful outcome. So what we'd like to do is regardless of the diagnosis, set appropriate goals and expectations with the patient, preferably from the get-go, which may need to be modified based on additional diagnostic testing or specialty input. But in this specific case, reassurance once we clearly identify and show empathy regarding the patient's symptoms and how they're presenting to us and explaining what the typical usual course is following a concussion can be very, very helpful to set that patient up for success. So for example, identifying the common post-concussional symptoms that the patient may already be presenting with or actually may ultimately develop diminishes that fear component for the patient should they develop some of those complaints. Really highlighting that the vast majority of patients with a mild traumatic brain injury will reach their pre-injury status within one to three months and sticking to that plan can also be helpful to set that person up for a successful outcome. And also, and Dan will talk about what the newer research shows regarding rest, but really encouraging safe and gradual and appropriate resumption of activities, both in the personal realm, but also as it relates to their work activities. And again, from an educational perspective, providing the patient with appropriate coping strategies so that they're not falling into that post-concussional syndrome after that one to three month period. Heather, next slide, please. So speaking as a clinician who has treated these patients, especially as a physiatrist, I like to think of it no differently than I think about someone who has an acute orthopedic injury or a significant orthopedic injury that needs appropriate orthopedic intervention. So as Dan has alluded to, the most common and significant risk factors, comorbid factors, confounding factors that can lead to that post-concussional syndrome delayed recovery would be pre-existing psychiatric issues. Other associated cognitive deficits, as Dan has just alluded to, a history and even more concerning active and inappropriate and unsafe use of drug and alcohol and the behaviors of possibly fear avoidance, catastrophizing and victimization, as well as evidence for secondary gain. Not only are these warning signs, but these should be indicators that it's probably beyond the expertise of an occupational health specialist who doesn't have expertise in mental health care that additional help and additional assessment is going to be indicated. If we stick our heads in the sand, if we ignore this and there are certain stakeholders that want us to ignore these issues, then I can promise you this will be a very frustrating claim for everyone involved. The patient will have a very poor outcome and even worse, there may be treatments that are inappropriate and unnecessary that the patient ultimately undergoes if they don't have appropriate assessment and intervention for these secondary issues. Next slide, Heather. So when should we start thinking as the non-mental health primary treating clinician when we need additional help? So as with any presentation, be that musculoskeletal, chronic pain, in this case, mild traumatic brain injury, when we fail to see improvement and when symptoms persist despite appropriate treatment, and as we know, there really aren't no significant objective findings based on definition of a concussion. Despite our appropriate initial workup, our initial treatment plan, this may be the time at one month that I start to consider not formal full neuropsychological testing, but what's probably a better term is neurocognitive screening. In other words, I want the expertise that, for example, Dan has to provide to give me more guidance of what are potentially the cognitive, the behavioral, the emotional, and the prior or preexisting psychiatric or mental health issues that may interfere with this person's recovery. When the patient persists with symptoms beyond three months, again, I keep in mind this one to three month timeframe. Again, despite appropriate treatment, they have ongoing functional limitations, then I really need to consider am I the right treating provider? Because most likely these obstacles are out of my scope of practice, namely the mental health, behavioral, and cognitive issues, and I'm not trained to provide the level of expertise that this person may require. And that's when I'll start thinking about actual referral. Next slide. Next slide. So to me, the most important benefit as the treater, somewhat different than the benefit that the patient will get by getting more information from the neurocognitive screening, is it will help me determine are the remaining symptoms, the remaining perhaps psychosocial mental health issues, something that I do feel comfortable managing, and then I'll continue as the primary treating physician without the ongoing expertise of say someone like Dan or perhaps a neurologist. If based on that additional testing, and that could be not just the neurocognitive screening, but that could be further consultations from an ophthalmologist, from a neurologist, if I think I'm gonna need some help in managing these ongoing symptoms, then I need to consider am I gonna co-treat with the specialist? And if so, it is really important to identify who that primary treating provider is going to be. Is it going to remain under my oversight or is it gonna be under the oversight of the specialist with my secondary expertise as the worker's compensation physician? And then the last issue, if the neurocognitive screening really shows significant cognitive, behavioral, emotional, psychological obstacles, then the transfer of care to the appropriate specialist, a psychologist with this expertise, we'll talk about treatment shortly, may be something that is most appropriate for that patient to achieve their highest level of function and recovery potential after their mild traumatic brain injury. Next slide, please. Dan, you wanna jump in on some of the overall guidelines for return to activity and to return to work decision-making and then I'll kind of narrow it down to some practical comments as well. Sure, thanks, Steve. But just to highlight what you were saying before, I mean, I've worked in all different roles with regard to the treating physician and quite often those are very different types of presentations and different types of situations. So we can obviously offer co-treatment as well as transfer of care when you wanna make the case strictly mental health. And usually, it works out pretty well, especially if we're able to do some clarification right up front and we have a better idea of what we're dealing with. The research literature has really not supported the old myth about people need a lot of time off after a concussion. And I would say that there's a realistic need to decrease people's independent gross motor activity within about a 24-hour window after a concussion because of the risk of secondary falls. So if someone's had a deceleration injury or blow to the head and there's autolithic organ involvement or ocular motor problems, it really can increase their risk of falling again. But it really depends on the person's job duties as well. So I always say step one should be looking at the person's job description and identifying job duties that can put the person at risk for re-injury or injuring others. So obviously, jobs that involve operation of heavy equipment or driving or conducting machinery, obviously, it's a limitation on the speed with which you can get people back to work. The step two is to determine the extent to which the person's presenting problems limit their capacity to do their job, which can increase the risk of harm and identifying specifically what it is about the injury that's causing that limitation on their job duties. And then in step three, you wanna offer some reasonable restrictions. Quite often, it's good to get input from the claimant and if possible as well, from the employer, so a supervisor at the employer or a transition back to work person working for HR at the person's employer to give you some guidelines about what is typical in that setting. And some employers already have guidelines and policies in place to help occupational medicine providers and mental health providers give guidelines about safe return to work for specific types of employees and the types of job duties they have that might put them at risk or put other people at risk. And then it is helpful as well to identify aspects of a person's job that they are able to do. And then one of the biggest problems we have is when people are taking completely off job that restricted from their work entirely. And then we're trying to transition them back into the workplace and we have cognitive plus emotional aspects of the return to work process that are gonna be affected. It's really difficult to get somebody from going from zero back up to fully working. So sometimes it's good to keep them involved in the workplace in whatever way they can. So if there's aspects of the job that they can safely do or there's modifications to the job that the employer is willing to make, then those are really useful. So that kind of gives you the outline of return to work planning. Thanks, Dan. Heather, next slide, please. Dan, I'm gonna kind of keep us a little bit tight with time but if you can just do a somewhat deeper dive into what some of these cognitive limitations are, that would be helpful. Yeah, the primary issue is gonna be stamina and basically sustained mental effort. And that can affect their ability to ambulate in the environmental setting. It depends on the type of environment where they working if there's a lot of uneven footing or they're dealing with wet conditions or they're working outside and may have to negotiate some difficult terrain. They have to be able to sit and stand to accomplish tasks as needed to maintain their usual rate of activity at an expected pace in order to keep up with the task demands and maybe working with a group or be part of a chain of accomplishment at work that may be affecting other people's ability to get their jobs done. They have to be able to sustain effort as long as necessary for the task. And in the meantime, identifying potential risks or hazards that may be coming up in the work environment. Being able to, these are things that most occupational physicians are comfortable identifying which is difficulties with holding or carrying or lifting heavy objects while at work. And then obviously tool and equipment use is very important. And so these are all factors that could affect a person's safety. And these are issues that need to be addressed in a work status evaluation. Thank you, Dan. Next slide. Dan, a little bit on the importance of focus from a cognitive mental perspective, especially based on what some of the job and life demands may be for that individual. Yeah, these are the ones that most people would recognize as being executive or frontal lobe functions where your orientation or alertness to particular environmental stimuli isn't going to be inhibited. You can identify dangers in your environment, adjust your behavior accordingly, inhibit off-task or impulsive behavior. So inhibition of off-task or impulsive behavior is the common feature of frontal lobe dysfunction. Getting things done on time. So self-monitoring and self-management is really an important aspect of executive functioning. And then keeping a schedule both daily and on a weekly basis is something you'll see people drifting off from if they're not monitoring themselves carefully. And then being irritable and inappropriate at times in the context of getting feedback from authority or from coworkers is something we can also see with the population of people who may be having decreased level of frontal lobe functioning. Next slide, please. So Dan, what you just shared in the two slides is just brilliant. I know that some of the clinicians on the webinar are thinking, well, I don't have enough time to be able to identify what all those potential functional limitations may be. So with being very respectful of the reality of the practice that we're in, let me just give some general suggestions on what may be considered when you're completing your activity prescription. Before I go through this in detail, I'll just give a few additional personal comments. And again, not specific to post-concussional syndrome or mild traumatic brain injuries. Our job as clinicians is to identify what activities, and in this case, probably what type of environments are safe for the individual while they're going through their healing process. Our job is not to provide work accommodations. Now, our activity recommendations should be clear. They should be understandable. They should be actionable. They should show advancement if we're giving appropriate treatment and the patient's improving. But the work accommodation issue is as the name implies, up to the employer. So they get to determine where, how, when, and if they can accommodate a type of work environment based on our clinical activity recommendations. And the only other comment I would make is because the patient doesn't have two different bodies, one at work and one outside of the work environment, our recommendations apply to that individual, not only at work, but throughout their daily activity, be that at home, in the community, when engaging with other people, be that social or leisure activities. So what you'll see in this slide highlighted in red is that it's oftentimes not only the environment at work that this would be relevant for, it's also the environment in which the patient is exposed outside of work. So just very briefly, depending on the patient's presentation and what their symptomatology may be, limiting exposure to high sensory input can actually be helpful. So one recommendation that the primary treating clinician can make is patients should work or should engage in activities in a quiet environment. That would be true at home and that would also be true at work, if clinically necessary. Introducing that patient to new and perhaps stressful or novel situations gradually with support of others in the workforce, this may be the supervisor or their coworkers can also help transition that patient into a successful functional outcome and providing written instructions can also be very important, especially when the patient is going to be asked to perform new information and breaking those down into small discrete steps to help that person be successful in implementation. Avoiding stressful activities, I understand a bit nebulous, but I think we all know what those kinds of stressful activities may be. Again, that would be relevant to the patient at home, at work and in the community. And developing memory cues that can help guide the patient who may have some memory or higher level executive functioning challenges. Before moving on to a new or an additional task, making sure that the person is able to focus on a single activity can also be helpful in documenting on our activity prescription and not recommending total disability for a long period of time, but really focusing on gradual increase in activity levels, both at work and outside of the workforce can be very helpful for a successful transition. Next slide. I'm not gonna go through the next two slides in detail. The only reason I'm including this is, as I mentioned previously, we will provide the PDF of the ACOM practice guidelines for traumatic brain injury. And as you can see by the title, this information comes directly from those practice guidelines. Next slide. Just another way of looking at how disability durations can be understood. This could be a whole additional presentation, but very briefly, you don't see zero. Zero would mean patient is not to be engaging in any life activities. So you can see that within a certain amount of time, depending on the symptomatology and the level of activity requirements, the patient should be expected to resume some level of safe engagement relatively early in their presentation. Next slide. So let me make a few comments and then I'll turn it back to Dan. As with any diagnosis, and if we're providing compassionate, empathetic care, showing that empathy, identifying reassurance once we really prove to the patient that we hear and we understand their perspective and setting return to activities and overall clinical improvement should be what we do sooner rather than later, and preferably at that initial visit, not setting those expectations when we see the claim is going south or we're having some challenges. Majority of patients, and I think this needs to be reinforced with the patient, return to work within one month and identify what referral options you may have should you need additional neurocognitive assessment. I like to think about that at one month if the patient is not showing the expected functional improvement, and then what your potential referral options may be for either co-treatment or actual transfer of care to the appropriate specialist, which in this case for post-concussional syndrome will most likely be a mental health specialist. As in any clinical presentation under the Wilcom system, having a very strong, healthy, communicative relationship with your claims staff, with the claims examiner can help assure that the patient is getting the appropriate treatment under the appropriate benefit system. Next slide. Dan, this is where you can get the ball out of the park regarding what you really identify now as the most timely from a research evidence perspective as it relates to providing the highest quality of care for these patients. Thanks, Steve. Yeah, I recently published a paper on trying to improve outcomes for this class of claimant and did pretty extensive lit review on the topic. As I mentioned earlier, not a lot of people are supporting prolonged rest or recovery post-concussion, and a lot of times that can kind of backfire. As I said, you can lead to anxiety, avoidance of the work environment, along with deconditioning, and then sometimes there's a kind of inertia that gets built up with people just being off work for a period of time and out of that loop, and they get out of their usual sleep-wake cycles and their usual activity rate drops. Generally not good for folks to be doing that for very long. The big factor in the research seems to be dealing with the negative emotions that come with the injury, and whether that's resentment towards the employer or towards co-workers or anybody else that was involved in the injury, sometimes there's resentment towards people for not acknowledging or in a way almost respecting the level of discomfort that they experienced as a result. So even though we're trying to be reassuring that there isn't going to be any permanent injury, at the same time we have to let them feel that it's acknowledged that this was an aversive experience and a very painful one. The anxiety about the injury is also fairly common in people who don't have much knowledge or experience with medical care provision, so they quite often will have peripheral extracranial kind of symptoms, and they think that this means that there's something seriously wrong with their brain, or they're having mild difficulties with attention and memory, and they think these are permanent symptoms. People often over-interpret the media presentations on chronic traumatic encephalopathy, you know, they hear about boxers and football players and they think, oh, you know, I bumped my head and now I have this horrible condition, and so they get really anxious about it, or just being off of work and missing out a lot of the social support and the, you know, the daily sort of positive affirmations we get from, you know, doing our jobs and connecting with other people and feeling that we're effective in the world that can change our sense of identity and lead to some, you know, negative outcomes like depression and social isolation. So it is important to recognize that post-concussion syndrome really is a mental health problem that can be addressed quite easily if we catch it early enough. Sometimes there is, again, a kind of an inertia that sets in and people will have committed to a lot of work avoidance or other kinds of, you know, sometimes statements about their symptoms and you get a kind of cognitive dissonance setting in where they now have kind of accepted that they're telling a story about how they were injured and how it affected them, which makes it harder and harder for them to return to work. The vestibular physical therapy is very common. I've seen people pull that trigger over and over again, sending them for physical therapy over and over again without realizing that maybe they need validity testing or mental health input. If the standard treatment for the dizziness or vestibular problems, which is physical therapy for a couple of weeks, doesn't work, don't just keep pushing the button over and over again because it's not going to work the second time or the third time. You know, you need to start looking at alternatives right away if the person is presenting with symptoms, they're not remitting, and especially in the context of a less than credible medicalism of injury. Next slide, Dan, thanks. You know, as I hear you say that and look at the slide, you know, absent a significant, for example, musculoskeletal injury, those recommendations apply just about to any clinical presentation in which the patient is not improving as would be expected or in which there are a lack of biomechanical objective findings that could account for the patient's ongoing symptoms. So I will remember that slide not only for MBTI presentations, but many musculoskeletal presentations as well. If you wouldn't mind going into more detail, actually we're doing well on time, and talk about an actual model, especially as you and I have both been referring to with regard to neurocognitive screening and distinction to formal neuropsych testing, validity testing, and really importantly that you may be seeing these patients in your role as a neuropsychologist, but we're not referring them to you with a specific psychiatric diagnosis. It's really to provide further input as to what may be some of the obstacles and then considering treatment like CBT. So if you could go into a little bit more detail about what that treatment and assessment plan looks like, that would be great. Yeah, essentially what I found was that there were a lot of cases with very mild presenting mechanisms of injury that were showing these very prolonged periods of delay for return work and recovery of reported symptoms. And a lot of them were being referred for neuropsychological evaluation because of the memory complaints, sleep disturbance, difficulty concentrating, fatigue, all kinds of post-concussive symptoms. Some with the diagnosis of post-concussion syndrome, you know, the F07.81 ICD code, and others with just a concussion or physical diagnosis, others with the diagnosis of a concussion plus an adjustment disorder or a rule out of some kind of somatic type of condition like a psychosomatic problem. But a lot of them boiled down to the similar kind of clinical presentation which is essentially a work-related head injury followed by delayed recovery with a lot of mental health overlay. And because of the delay in getting these people in to see a neuropsychologist, the expense of getting a comprehensive neuropsychological evaluation plus the time delay for the evaluation to get done and then for the report to be written, I decided to try to institute a screening protocol for this population where we could have general psychologists do a computer-administered cognitive screening. And you can use standard screens. Psychologists do psychological testing, not just neuropsychologists. So general psychologists can do a cognitive screening to determine if the person has residual cognitive difficulties. The problem there is it's not always easy for people who don't do a lot of psychological testing to distinguish between psychological or cognitive problems and then effort problems. Effort testing is a kind of a nuanced area that's more specific to neuropsychology. And that's where we're making a distinction between having a cognitive problem and then just not trying very hard when you take the test. And it turns out that there are some pretty clear indicators. People think, oh, how do you really know that this is not just the person's having difficulty versus that they're not putting in a true effort? Well, it turns out that we have tests specifically for that. One of the best ones actually is just what we call reliable digit span, which is that the old digit span test, how many numbers in a row can you remember? Well, if you score very low on that based on a concussion, that doesn't really jive. It turns out to be a very, very reliable measure of memory malingering is if you score low on something simple like a straightforward memory test, short-term memory test. But what we've been using is something called the CNS Vital Signs, which really improved our ability to reach out because it's a computer-administered test that you can take online. And it's still a pretty thorough test. It's about a 45-minute assessment of a range of cognitive functions from complex attention, short-term memory, visual and verbal short-term memory, rational reasoning. And there's a Stroop test in there, which is an executive functioning measure, finger tapping speed. So we get psychomotor speed. And because of the assessment is administered by a computer, it also measures a lot of variables with regard to the types of errors that people are making, commission versus omission errors, and their response rates on different types of errors. So it collects a lot of data in the 45 minutes. And a lot of people don't realize that the computer is collecting those kinds of variables since they're not directly related to the questions that they're answering on the computer. It's the way they're answering the items. And a lot of those variables can be used to come up with measures of symptom validity or effort testing. And so we get a pretty clear picture using that assessment tool. And a general psychologist can implement this in 45 minutes. We usually combine that with the MMPI and then other test measures that are sensitive to changes in affect, like depressed mood and then anxiety. We use the symptom checklist 90. So we get a pretty clear picture of what's going on with them in terms of psychopathology, as well as effort and then over-reporting of symptoms. So we have measures that are specific to assessing non-credible psychiatric symptoms. So certain kinds of symptoms will be under- or over-reported, but then there's other types of symptoms that are just not very likely. They're just on the face of them, not credible symptoms. And there's a lot of those on the MMPI. So the MMPI-3, the CNS Vital Signs, which is a computer-administered cognitive battery, the NSI, which is a neurocognitive screening battery that's used for assessing specifically post-concussive symptoms, which has a validity indicator built into it, combined together, take up about two hours of time, but provide a very comprehensive review that can be done by a general psychologist. Now, if in that screening, if we find that there are signs that the person does have lingering issues, or there may be comorbid problems secondary to some other issue that may have been related to the fall or a driving accident or something. So if someone had other kinds of neurocognitive, non-industrial neurocognitive problems that led to the injury, we are able to pick up on those. And we typically then refer them to neurology, refer them back to occupational physician or to physiatry, or we refer them to a neuropsychologist or all of the above. So the screening is really a key tool because once we have that in place, then if the symptoms are either malingered or inflated for some other reason, whether it's psychosomatic or the person's had a pre-existing depression or something, we can make appropriate referrals and get them treated and rolling again a lot faster than just waiting another three or four months to get a neuropsychological evaluation done. Again, the only thing I would add to the, just the great information you shared is, as I mentioned just a few minutes ago, this is really we're having an effective relationship with your claims examiner and educating them as to why and how these secondary issues that are now being identified really need to be addressed and then identifying which benefit system may be best in addressing those issues will lead to a positive outcome for all, will minimize frustration on everyone's account, and will actually minimize costs by providing the patient with the appropriate care. In other words, as I mentioned also earlier, these issues should not be ignored. They need to be identified and then addressed under the appropriate benefit system. Yeah, and typically if we find that the person is either loading very much in a psychosomatic kind of category where this person really believes that there's something seriously wrong with them and they're just kind of stuck in that mode and they can't really get over the fact that they had this hit on the head and they're still a little dizzy, they don't really trust what the doctors are telling them about them being, you know, able to recover fully, or they're at the other end where they're, it's pretty clear that they're milking the system and they're really being strategic about how they're using workers' comp, and then there's a gray area in between where people are kind of a bit of both, where they're sort of taking advantage of what's coming their way in terms of, you know, being off work and having wage indemnity and then getting a lot of attention maybe from, you know, providers and having a lot of secondary providers involved, you know, as well. So sometimes it's a combination of factors, but in any of those cases our approach is going to be very positive. You know, we don't tell people, oh, we think you're malingering or, you know, you're lying to us, we don't confront people, we just give them the feedback, oh, good news, you know, your brain seems to be working well and you're going to be able to get, you know, you're going to be able to move on. So we're able to give them very good feedback, they feel thoroughly evaluated and they are, you know, carefully scrutinized and given all the attention they need, and then we establish a therapeutic relationship with them. So we get a sense of what their needs are in terms of their getting over the emotional hurdle of return to work and giving up their resentments, not feeling depressed about it, alleviating their anxieties, there may be something seriously wrong with their brain as a result of this injury, and just sort of reassuring them that, you know, these are the symptoms you're experiencing and you're going to get over them, or letting them know, well, this doesn't all really add up, but the good news is it looks like you're fine and you should be able to move forward. And the good news is the research from that, taking that particular approach, shows that we were able to cut the duration of return to work time dramatically. So from an average of 10 months being off work, we were able to cut it down to an average of seven weeks. Yeah, I'm going to, because that's such an important outcome in a successful manner, I'm going to have us run through these slides to get you to some of the last slides to really talk about what that research shows. So Heather, if you can jump to the next slide, and then the next slide. Yeah, and if you could start here, because I also found this fascinating, that would be really helpful, I believe, for the participants. Yeah, this was kind of interesting. This was an unexpected finding. I didn't really expect to find any gender differences at all. The occurrence rates were not really different for us, which was kind of interesting, because men actually tend to have a little bit more physical jobs on average, and they tend to be exposed more to physical kinds of injuries like this. But with the combination of mild mechanisms of injury, a lot of slip and falls, and just kind of bumps on the head, it wound up being fairly even in terms of gender presentation overall. But interestingly enough, women who presented with these issues were often more likely to be diagnosed with a mental health problem, and they stayed in therapy a lot longer than the men did. The men actually took longer to return to work, but their symptoms stayed medically diagnosed, and they quite often were referred to us under the HBAI codes. So there's two different approaches for us to get involved in sharing the case, either as treating the mental health problems, and again, you know, post-concussion syndrome is a mental health problem, so we would get involved in treating that as mental health providers. But a lot of times we're also involved in kind of co-treating or, you know, being a secondary provider under HBAI, health behavior assessment and intervention codes, for just treating the tinnitus or sleep disturbance or, you know, mild adjustment issues that may have come from the head injury. So it's like chronic headaches or cervical pain or mild memory loss, and we're providing services without a psychiatric diagnosis. Those are more likely to be male, and so the women seem to be a little more comfortable and the people working with them a little more comfortable in talking about this as a mental health issue. And with the men, we seem to be to be more in a sort of safe conversational space with them, talking about this as a physical issue, but actually that kind of slows them down. Their return to work was actually longer than the females. So it seems like what we should do overall is really get to the point, which is you're having a mental health problem and you need to talk to a psychologist about this, and they'll get you through it. And that seemed to be the best. And so recently, you know, so after we've been doing this for over a year, these screenings, we've been getting more referrals earlier. And so, you know, now we're seeing people who are being referred a couple of weeks after a concussion and not a year or more. And our turnaround rate is about the same. So whether you refer the patients to us after two weeks or you refer them to us after two years, it still takes us about a month to get them back to work. Fascinating. Next slide, Heather. Then you want to go through this colorful slide because it'll sort of help reinforce what you just mentioned. Right. So this is the lost work days from the date of injury to the date of the referral to us for a neurocognitive screening evaluation. That's the first bar. And there's divided up from, you know, the total and then all females, all males, those who were diagnosed with a psych condition, those who didn't have a mental health diagnosis, and then males with psych diagnoses, and then all medical conditions where you treated them as HBAI. And then it's broken down by gender there. And as you can see, the longest group of all were the males who stayed on the medical side who never got a mental health diagnosis. And their total average of lost work days was 293. And after their referral to us for a neurocognitive screening, the average length of time to return to work was 37 days 36.7. And then on the total on the left, there were 202 average work days lost to post concussion prior to referral. So these are people who had a concussion. And by the, you know, by the time they got to us, they had been off work for a total there been compensable last work days 202 days. And then after the time they were referred from the time that we got the referral at the time we were able to get them to a provider, get the evaluation done, have them seen, get the report, have the report given to the patient, discuss the report set up a treatment plan, have them come in for therapy. Do you know the actual modal number of therapy sessions that people attended was one. Because we were able to sort of package it all together for them and say, Look, you've been off work for a long time you had a concussion, you're probably better by now and our test results suggest that you are better, but you're kind of depressed. And these are the kinds of things that you need to do to get over that hump, including going back to work. And there's no reason right now that you can't go back to work tomorrow. And so that's what we're going to recommend. And so as you can see it took us about a month to get people back to work after 10 months off work on average. Dan this is truly remarkable information. And without tooting too loudly your horn, my understanding is now that this is no longer in print or preparation it's now been published. If you just want to make a quick call out to how the participants may be able to actually read, to find that article that would be great. Sure, you just go to the J OEM website, and there's a search engine there, you can either find the article directly by typing in one of the authors names including mine or just type in concussion, and the article will will come right up. Great. I'm going to bring us to closure so that we can answer some of the questions I see them coming in. I'll just make a quick comment, and then turn it over to Dan for his closing comments. So what I would say is just based on the research that Dan has just presented, it sort of highlights the clinical importance, not unique to MBTI or post concussion syndrome, but with any presentation if the patient is not showing the expected improvement, from an emotional perspective with ongoing symptoms, getting an evaluation be that a consult be that the neurocognitive screening is so critical and doing that sooner rather than later as I mentioned previously, I like to use kind of a one month to six week rule, really can identify where the obstacles are and then allow the appropriate special specialist to intervene with as Dan has just shown us rather significant positive outcomes so Dan thank you for what you presented any other additional comments before we open it up to the Q&A session. Yeah, just one last thing I've noticed that recently that some of our providers are waffling a little bit on the issue of whether or not to say the person does not necessarily have a diagnosis and should go, you know, back to work. And they're really being sort of sympathetic to the presentation of psychiatric or affect or anxiety type symptoms. And even though the evidence suggests, based on the testing that the person is not presenting with valid neurocognitive features. And in my experience, if the person is showing signs of symptom magnification, and their effort level on the testing is invalid. That's the conversation you have to have you can't just move on to oh it must be an emotional problem. Because they're going to malinger that just as easily. And I've seen it happen now a number of times where people are kind of like, oh well you may not have a neurocognitive problem but I can see why this was really traumatic for you emotionally. And they wind up going down the road with that and it lasts just as long as the recovery process so I think to some extent we really need to be firm that the best thing for the person is to return to work and recover quickly. And if they need an emotional support for that that's fine. But, but we can't just move the delayed recovery from the occupational physician to the psychologist, and let them do the work statuses that are going to extend it. It really needs to be no no no the best thing for you to go back to work, honestly. And if you need some support in that process will offer it, but, you know, delayed recovery to return to work is is should really not be an option. Dan, I again I can't thank you enough for your wisdom and what you've shared with us today I'm going to turn it over to Heather to help us with the q amp a component of the talk. Thank you both so much. Just a reminder if you do have a question please post it in the q amp a box, and I'm going to go ahead with start with the first question at what time should the clinician asked the patient. If he or she expects to be able to return to work and usual activities. Is this best asked at first presentation, or if recovery seems delayed. So, Dan since I sort of alluded to it I'll give my, my opinion which is really based on clinical expertise, but would certainly value of any input you have. So to me the best time to set expectations to set realistic goals, realizing that they may need to be modified if additional objective information is obtained, and to ask that question is at the first visit, because it's really another way of showing empathy to the patient that you've listened to them that you put them yourself into where their position is. So I can't think of a reason not to ask that question initially, except if you're really waiting for additional critical diagnostic information, let's say you are concerned about an intracranial bleed obviously that's a red flag you want to get more information, but in most of the presentations that at least I have seen asking that question initially, rather than waiting until there's more challenges is usually the same way I wouldn't want to wait until that case is going in the wrong direction to start setting expectations and goals. Dan any other comments, especially if you disagree with that approach. No, not at all. I would suggest looking at it as a, you know, from a risk point of view. If the person's not going to be putting themselves or other people at risk of harm. Obviously that you want to try to emphasize that the best thing for them is to to get back into the game and we've had this conversation before Steve where I say it's, it's like if you get a flat tire on the highway you know you don't want to be sitting there looking at that flat tire for very long you know put the spare on and keep moving. There's a lot of bad things can happen on the side of the road. Great point. Our next question is, can you please comment on the patient that has sunglasses syndrome. Dan I'll defer to you on that one. By sunglasses syndrome I think they mean photophobia lingering photophobia. That's almost, in my mind synonymous with malingering is there's no credible neurophysiological basis for that. People can wear you know headphones or wear sunglasses. If you actually look at the psychophysical component of the amount of light that's being transmitted at various times to the eye and the perceptual functioning it doesn't make any sense. So, lingering I mean photophobia is interesting you do get sluggish pupils after getting whacked on the head so you can have photo, you know, photophobia can last but it's usually hours, not months or weeks or years. It's a very brief symptom and resolves usually fairly quickly. If someone has really lingering photophobia. It's usually a more serious neurological issue or ocular motor problem not ocular motor but ocular problem if they need to see an ophthalmologist, but in my experience it's it's very very common and people that are magnifying symptoms. I have nothing to add. Obviously if there is a an objective reason to account for any ocular symptomatology then referral to the ophthalmologist makes perfect sense but Dan I think you hit it exactly on the head this is usually an indication of some type of secondary gain issue doesn't mean that it shouldn't be addressed I'm not saying that these are people who are consciously feigning automatically or malingering, but this is where your expertise with the neuro cognitive screening or that of a psychologist can be very very helpful. Yeah, the amount of help the amount of light that is reduced by by sunglasses is trivial compared to the source of the light outdoor bright sunlight is is literally 10,000 times the lumens of a computer screen. If they walk outside and then come inside sunglasses aren't making that much difference they decrease the exposure to luminance very very minimally relative to the type of light indoor outdoor, so they come in from outside and they come to an appointment and they say oh I can't look at the computer screen or they have to put sunglasses on indoors. Heather let's take one more question because I think we have about a minute and then Dan and I are happy to stay on for an additional five minutes on that would be helpful. Very good. Okay. Is there much merit to keep work shifts work shifts short initially and gradually increase, for example, a four to six hour shift instead of an eight to 10 hour shift. Dan, um, you want to take it and then I'll add my comments I actually call that a real work conditioning program regarding regardless of the diagnosis that you're helping the person be in the work environment and then providing with a gradual increase in tolerance What are your thoughts about that specific to MBTI. Yes, I think that's quite reasonable especially early on, but you're looking at maybe a couple of weeks of that don't start thinking about months and months of transitioning to full workload. Briefly it is especially if the person does something where they have time limit, you know, limited response, you know, driving a bus or they're driving a truck or they're operating heavy equipment for long periods of time and they have decreased concentration and sustained mental energy. That's a very reasonable approach. Yeah, the only thing I would add to that is, it's part of my setting realistic goals and expectations as it relates to returning that person to their life activities and work so I really want to set an expectation that this isn't going to continue for the next six months, it will be a very short duration for this work type of reconditioning approach for job reentry. Okay, we have several more questions. How useful is visual or occupational therapy for TBI. Dan you had alluded to this in some of the research, why don't you go ahead and take that from what that research may support or not support. It won't be a popular thing to say but it doesn't get really strong support. Vestibular therapy is very common occupational therapy, any kind of visual therapies, those are usually specific to certain kinds of focal deficits. And what we know about concussions is they don't cause vocal injuries. So unless the person has a focal neurological problem which would not be from a concussion would be from a different kind of neurological injury. So those kinds of interventions are probably not supported. I mean, the only thing I would add to that is, if we're now talking about a post concussional syndrome rather than just the initial concussion, as it is a mental health response. It doesn't make a lot of sense to me and I'm not criticizing physical therapists that you know they get our patients better occupational therapists do a great job. There's no reason to undermine their expertise. However, if we're trying to use that type of therapy for mental health diagnosis, then that doesn't make a lot of sense to me let's get the appropriate screening done. Let's get the appropriate intervention based on those screening results and most likely that's not going to include depending on the symptomatology and the findings vestibular or occupational therapy. Someone was wondering when you said most return to work within one month. Did you mean return to full duty. The research does show that that yes most people with mild traumatic brain injuries do return within one to three months. Now, what we remember is not our success stories we remember the most challenging stories but that is a full return to work now, obviously there are nuances in that depending on the job demands is not as Dan went through regarding the executive functioning of that job the safety concerns, but for the majority of the vast majority of people they will return to work within one to three months and that's their full return to work status. I have two somewhat related questions one person is asking, how do, how would you suggest I try to find a psychologist that would be willing to provide a neurocognitive screening and another one was just asking how widely available our neurocognitive screening evaluation services. Dan, let me jump in from sort of because this is a great question I'm glad it was raised as a treating clinician in my role with our occupational service line. You have to work with your claims examiners there are various networks of well trained mental health specialists that can do the type of services that Dan alluded to, but you have to make sure that you're educating your claims people on why it's important and what the benefits will be to all of the stakeholders, especially the patient and then work collaboratively to identify what may be the appropriate clinician, let alone a network that can provide that service. Dan, please jump in this is again your area of experience and expertise. It really depends on the level of training of the psychologist that's involved. Some general psychologists have a lot of background in health behavioral health and in workers comp and in neuropsychology without necessarily being board certified as neuropsychologist. If a psychologist looked at the study that we just published, there is nothing in there that they as a general psychologist wouldn't be able to administer and interpret. So the MMPI the neurocognitive screening battery that the CNS vital signs. The NSI. Those are all tools that general psychologists can use. And I think the general idea is that if you combine a cognitive screening tool with some measures of both symptom validity, and then psychopathology, like the SCL 90 or is an excellent example of that, you will be able to identify the areas that need treatment from a behavioral health point of view, or the areas that need confronting from a healthcare point of view in terms of being able to support the person to move along. If it is mostly symptom magnification. And if, if a general psychologist is used to working with the population we're talking about which is workers comp. In terms of the question with regard to how do they find someone locally. That would really depend a lot on their geographical location which we don't know. But we have a nationwide panel, our organization, a cell is health. And we you know we have providers like all across the country that can do this kind of evaluation. But I think if people read the article they'll get the you know most psychologists would read it and go oh okay that's what they're doing and they would know. They would know equivalent measures or you know how to basically come up with with a screening assessment like this that would move people along a lot quicker than waiting to get a comprehensive neuropsychological assessment. Okay, one final one final question and then any that we didn't get to we'll try to get answered offline, but we have a question how long has the medical community thought of PCS as a mental health issue I have not heard this until now. I have been using PT and neuro cog testing but have not heard any of these specialists communicate this approach. And I'll let you take that and I'll give you my just my personal experience. There is a type of post concussion syndrome listed in the DSM it's not there anymore there is no post concussion syndrome in the American Psychiatric Association, DSM five in the ICD 10, it's always been a mental health diagnosis, it's always been an F code. So it's a physical injury to the head is a concussion post concussion syndrome has always been an F code, which means a mental health disorder. So it's such a great question, and it's timely because it's so relevant, I'll give you my experience again. I would say that it's only been within the past probably two to three years and this is just based on my experience that the general medical community and really more importantly in some ways the claims community have identified that the delayed recovery of most patients with concussion resolved within about one to three months. So it's been relatively recently that the education and the discussions have changed to say, wait a minute, let's not ignore those individuals that take longer than three months. Let's help to identify what the reasons are and provide the treatment, but bottom line it's been a relatively recent medical community claim community understanding. And unfortunately, I would say, except for the people now who have participated on this webinar, you're the, you're the very small majority that really understand why this is so important so whatever you all can do to help educate the people that you work with the clinicians and or the claims teams and the nurse case managers use reference to the material in this presentation, it will help our patients get the appropriate treatment and bring these cases to timely and clinically appropriate closure. Thank you so much Dr Wiesner and Dr Legoff on behalf of ACOM leadership, thank you so much for presenting today. As a reminder, today's webinar was recorded a link will be emailed to all registrants, please check the ACOM website often for new webinars. For those of you who may be interested in applying for a comes prestigious excellent corporate health achievement award please visit a com.org backslash ECH a and to our attendees. Thank you so much for joining us today. Have a great day and everyone please be safe. Thanks again. Thank you, Heather. Thanks. Thank you. Bye bye. Thank you.

Managing Concussion

Post-Concussion Syndrome

Workplace

Symptom Identification

Goal-Setting

Patient Expectations

Assessment

Physical Symptoms

Cognitive Limitations

Neurocognitive Screening

Job Duties

Executive Functioning

Frontal Lobe Dysfunction