Occupational Therapy Interventions After a Sports-Related Concussion

Abstract

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project and illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making. Each article in this series summarizes the evidence from published reviews on a given topic and presents an application of the evidence to a related clinical case. This Evidence Connection article presents a case report of a college student receiving occupational therapy services after sustaining repeated sports-related concussions. The occupational therapy evaluation and intervention process is described. Systematic review briefs on interventions for people with traumatic brain injury were published in Vol. 76 (Suppl. 2) of the American Journal of Occupational Therapy.

This Evidence Connection article describes the occupational therapy evaluation and intervention a college student received after sustaining repeated sports-related concussions.

Meredith is a 20-yr-old 4th-year college student. She has been a soccer player since age 6, and she is on the university soccer team. Meredith was referred to outpatient occupational therapy with a diagnosis of repeated sports-related concussions 2 mo before the referral. Her subjective complaints included difficulty in reading both electronic and hard-copy materials and staying on the computer for longer than 30 min at a time. Meredith also reported four falls. She described them as “I just feel swaying, and the next thing I know, I am on the ground.”

Occupational Therapy Assessments and Findings

Mee-Sum, Meredith’s occupational therapist, completed the initial occupational profile (American Occupational Therapy Association, 2021) and noted the following findings:

Meredith lives with two friends in an off-campus apartment. The unit is on the second floor, and the building does not have an elevator. Meredith has the master bedroom, which has its own attached bathroom.

Meredith majors in biochemistry, and her goal is to apply to medical school after completing her undergraduate studies.

Before the concussions, Meredith was doing well in her classes, with a cumulative grade point average of 3.8. Since the diagnosis, she has received accommodations; she is permitted to audiotape lecture materials, take breaks as needed in lecture and laboratory classes, and work with a flexible schedule of assignment due dates and extended examination times.

Since freshman year, Meredith has volunteered at a local skilled nursing facility 1×/wk. She transports patients in wheelchairs to and from therapy.

Meredith likes nature. Throughout the year, she hikes with her friends regularly.

Meredith’s support system includes her parents, who live in another state but FaceTime with Meredith regularly. Meredith is close with her two roommates, two friends from the soccer team, and her soccer coaches.

Since the concussions, Meredith has found it challenging to participate in soccer practices. She describes difficulty in accurately locating and passing the soccer ball: “Sometimes, I don’t see the ball coming.” She reports having headaches and feeling dizzy and nauseated during practices. Meredith has been excused from soccer practices for the past 2 mo.

Meredith experiences similar symptoms of frequent headaches, dizziness, and nausea when she reads both printed and online materials: “I often have to sleep off the headache.”

Meredith uses speech-to-text software to complete her written assignments, and she listens to lecture materials while studying.

Meredith finds that she can attend to material better during early morning classes. She finds it difficult to follow classes if she sits in the back of the room. Since the concussions, she arrives in classrooms early so that she can sit in the first row.

Meredith receives counseling services to manage anxiety symptoms. She described her anxiety symptoms as including heart palpitations, sweaty hands, nausea, and stomach upset. She also noticed that she has more anxiety when she is in the dining hall, the library, and community shops and malls.

With the information from Meredith’s occupational profile, and because of her frequent headaches, dizziness, and nausea, Mee-Sum decided to explore her visual and vestibular functioning. To assess visual acuity, contrast sensitivity function, visual field, oculomotor function, and visual attention and scanning, Mee-Sum completed the Brain Injury Visual Assessment Battery for Adults (Warren, 2006) with Meredith. Meredith also completed the Brain Injury Vision Symptoms Survey Questionnaire (Laukkanen et al., 2017) and the Rivermead Post-Concussion Symptoms Questionnaire (RPQ; King et al., 1995) as self-assessments. Because of the high-level motor performance associated with Meredith’s soccer playing, Mee-Sum administered two standardized assessments of balance and vestibular functions: the Community Balance & Mobility Scale (Howe et al., 2006) and the High-Level Mobility Assessment Tool (Williams et al., 2006). Last, Mee-Sum used the Canadian Occupational Performance Measure (Law et al., 2014) to obtain client-focused performance information from Meredith. The assessment results are summarized in Table 1.

Mee-Sum reviewed the assessment results with Meredith, and together they set goals to address the vestibulo–ocular and balance symptoms, to improve Meredith’s essential skills for studying. Meredith’s goal was to complete the semester with good grades to maintain her academic standing.

Occupational Therapy Intervention

After reviewing the U.S. Department of Veterans Affairs and Department of Defense’s (VA/DoD’s, 2021) clinical practice guideline about the management and rehabilitation of post-acute mild traumatic brain injury and three systematic review briefs on vestibulo–ocular interventions, vision therapy, and virtual interventions for balance impairments as guided by the American Journal of Occupational Therapy (Kaldenberg et al., 2022a, 2022b; Li et al., 2022), Mee-Sum planned a multicomponent intervention approach that is summarized in Table 2. A referral to a neuro-ophthalmologist was made. The neuro-ophthalmologist prescribed a vision home exercise program with guided frequency and intensity.

Table 1.

Initial Assessment Results

Tool	Results
biVABA (Warren, 2006)	Meredith does not need corrective lenses and has 20/20 distant acuity and normal reading acuity in both high- and low-contrast contexts. Her visual field is intact in all quadrants. Meredith has demonstrated convergence insufficiency, and her saccadic eye movements to the lateral left and lower diagonal left were more prominent than those in other areas.
BIVSS (Laukkanen et al., 2017)	Meredith scored 68 out of 112 on the BIVSS. (Higher scores indicate more difficulty with visual tasks.) She rated “occasionally” to “frequently” in eyesight clarity, citing fluctuations in vision change as the most frequent problem. She rated doubling vision and light sensitivity as occurring “seldom” to “occasionally” and said dry eyes were never a problem. She stated having difficulty with both depth perception and peripheral vision “occasionally” to “frequently/always,” and she rated all statements related to reading tasks “always have difficulty.”
RPQ (King et al., 1995)	Meredith scored 37 out of 64 on the RPQ. (Higher scores indicate higher symptom severity.) A score >34 is indicative of moderate to severe limitations in abilities, adjustment, and participation in daily activities (de Guise et al., 2016). Meredith stated that dizziness and nausea were her most severe symptoms and that sleep disturbance, fatigue, poor concentration, and taking longer to think were moderately severe symptoms.
CB&M (Howe et al., 2006)	Meredith scored 80 out of 96 on the CB&M. (Lower scores indicate more difficulty with balance.) Her score was below the mean score of 88.71 for her age group (20–29; Clegg et al., 2009). Meredith had the most difficulty with the two walking-and-looking tasks and with dynamic balance tasks, especially balancing and pivoting on a small balance of support.
HiMAT (Williams et al., 2006)	Meredith scored 48 out of 54 on the HiMAT. (Lower scores indicate more difficulty with high-level mobility tasks.) She scored below the median score of 51 for a healthy 18- to 25-yr-old woman (Williams et al., 2009). Meredith was slower in skipping, bounding, and walking on her toes.
COPM (Law et al., 2014)	Meredith rated her performance in reading, writing, and attending class as 2, 4, and 5, out of 10, respectively. (Lower ratings indicate less satisfaction.) Her satisfaction scores for each of the three activities were rated as 1 out of 10.

Note. biVABA = Brain Injury Visual Assessment Battery for Adults; BIVSS = Brain Injury Vision Symptoms Survey Questionnaire; CB&M = Community Balance & Mobility Scale; COPM = Canadian Occupational Performance Measure; HiMAT = High-Level Mobility Assessment Tool; RPQ = Rivermead Post-Concussion Symptoms Questionnaire.

Table 2.

Multicomponent Intervention Program for Meredith

Strength of Evidence	Interventions
Moderate (Kaldenberg et al., 2022a)	A combination of gaze stabilization, balance, and sensory organization exercises that progressed from a stable controlled environment in the outpatient clinic to progressively more complex and dynamic environments in the community (i.e., school campus and shopping mall) was used: • Exercising using a tennis ball hung on a string. Meredith performed two exercises in a seated position: (1) turning her head from side to side while maintaining her gaze on the stationary tennis ball and (2) maintaining her head in a stationary position in midline while maintaining her gaze on the tennis ball as it swayed from side to side. Once Meredith was able to demonstrate the exercises in the clinic, they were assigned as home exercises for 20–30 min daily. As Meredith reported decreased dizziness and symptoms of nausea, the exercises were progressed to being done in a standing position. • Implementing balance exercises. Meredith participated in walking exercises with head-turning in all planes (i.e., side to side and up and down) on surfaces that varied from even carpeted surfaces in the clinic to foam surfaces and eventually uneven surfaces in the community. • Using sensory organization exercises. Meredith used postural control on varying surfaces and bases of support with or without gaze stabilization and postural control in visually dynamic environments, such as being on campus and in shopping malls with head-turning movements.
Moderate (Kaldenberg et al., 2022b)	Vision exercises. Meredith practiced convergence using Brock strings and pencil pushups and performed saccade and pursuit exercises as prescribed by the neuro-ophthalmologist. Mee-Sum incorporated the prescribed vision therapy as a primer to graded reading, computer screen work, and scanning in visually dynamic environments.
Moderate (Li et al., 2022)	Supervised Xbox video game with a Kinect Sensor. Meredith played graded games that ranged from single-limb guided movements while standing (e.g., arcade-like games, such as darts, hoop shoot, and table hockey) to complex whole-body tasks (e.g., Just Dance and Motion Sports).

Two other interventions in Mee-Sum’s multicomponent approach were (1) sleep hygiene and (2) a symptom self-monitoring tool with activity pacing strategies. Both fatigue and sleep disturbances are common in people with post-acute mild traumatic head injuries. In her initial results on the RPQ, Meredith reported having moderate symptoms related to fatigue and sleep disturbances. Therefore, consistent with the VA/DoD’s (2021) clinical practice guideline, sleep hygiene strategies (e.g., place electronic devices in the backpack, away from the bed; avoid caffeine drinks 4 hr before bedtime; and stick to a sleep schedule) were introduced to Meredith to enhance both the quality and quantity of her sleep. A symptom self-monitoring tool helped Meredith monitor and manage her symptoms of nausea, dizziness, and physical or cognitive fatigue during activities. The tool uses a 5-point scale on which 0 means there are no symptoms, no dizziness/nausea, and no fatigue; 1 represents feeling a little bit of the symptoms but being able to continue with the activity; 2 represents feeling nauseated, dizzy, and/or fatigued and needing a break from activity or using an activity pacing strategy; 3 represents feeling nauseated, dizzy, and/or fatigued and needing to stop the activity; and 4 represents feeling nauseated, dizzy, and fatigued and needing to sleep. An additional strategy included the creation of a self-management toolbox with activity-pacing approaches. The toolbox included the following strategies: taking rest breaks; listening to music; stabilizing one’s gaze on a stationary item in the environment; changing one’s body temperature, such as by using a cool washcloth on one’s forehead or washing one’s face; and maintaining the practice of mindfulness.

Meredith initially completed the symptom self-monitoring tool on paper every 5 min during occupational therapy sessions. She eventually loaded the tool onto her phone and scheduled reminders to monitor her symptoms in 15- to 30-min intervals throughout the day. Therefore, Meredith was successful in modulating her symptoms in different activities through the use of the symptom self-monitoring tool and the activity pacing toolbox.

Conclusion

Meredith achieved her goals after she had attended 10 occupational therapy sessions, first 2 times/wk for 2 wk, followed by a frequency of 1 time/wk for 6 additional wk. A reassessment was completed at discharge; the findings are presented in Table 3.

Table 3.

Discharge Assessment Results

Tool	Results
biVABA (Warren, 2006)	Meredith improved her convergence sufficiency to the point that she had no to minimal symptoms. Her saccadic eye movements to the lateral left and lower diagonal left improved, and she continued follow up with the neuro-ophthalmologist for vision therapy.
BIVSS (Laukkanen et al., 2017)	Meredith improved her BIVSS score from 68 to 22 out of 112 on the BIVSS. (Higher scores indicate more difficulty with visual tasks.) Most of her symptoms in handwriting and reading were rated as occurring “seldom” or “occasionally.”
RPQ (King et al., 1995)	Meredith improved her RPQ score from 37 to 7 out of 64. (Higher scores indicate higher symptom severity.) She no longer experienced symptoms of nausea or sensitivity to noise and light, and she rated her headaches, dizziness, fatigue, and sleep disturbances as no longer being a problem.
CB&M (Howe et al., 2006)	Meredith obtained a full score of 96 on the balance assessment. (Lower scores indicate more difficulty with balance.)
HiMAT (Williams et al., 2006)	Meredith obtained a full score of 54 on the high-level mobility tasks. (Lower scores indicate more difficulty with high-level mobility tasks.) She was able to return to soccer practice and said she was planning to return to competitive games in a few weeks.
COPM (Law et al., 2014)	Meredith rated her performance in reading, writing, and attending class as 7, 9, and 10 out of 10, respectively, and her satisfaction scores for the three activities were rated as 8, 10, and 10 out of 10, respectively. She also reported that she had resumed completing her studying and homework on the computer with no difficulty, and she used a pacing strategy to complete reading daily.

This Evidence Connection article provides an example of how occupational therapy practitioners can combine evidence from different sources and apply evidence from systematic reviews and practice guidelines to inform interventions for people with traumatic brain injury.

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