Finnish practices:
Cognitive assessment and
interventions
Kati Peltonen, psychologist, MSc, MA
University of Helsinki, Clinical Neuropsychology
Research Group
Cognitive assessment and interventions
1.
2.
Heads in the Game
Cognitive assessment
• Concussion management protocol
• Assessment methods
• Baseline cognitive functioning
3. Interventions
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Rest ,return to school/ to learn, return to play
Activity progression after mTBI
Cognitive Interventions. Heads in the Game
Future Prospects
Heads in the Game project 2015-17
Funded by Ministry of Social Affairs and Health.
Aims
• Awareness of concussions
• Concussion management protocol
• Interventions
• Professional network
Nation wide
17 clubs
51 teams
around 2700 players
70 concussions in season 2015-16
Concussion Management Protocol
• Baseline assessment before season
(ImPACT, K-D, D2-R, SCAT-3, ATTEX)
• Post-injury
• Sideline test
• Post injury- assessment (3, 7 ,14 and 30 days after injury)
• Physical and cognitive activity
• Comprehensive Neuropsychological tests if needed
Cognitive symptoms after
concussion
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Problems with memory
Difficulty concentrating
Feeling slowed down
Feeling mentally foggy
Cognitive assessment:
Sport Concussion Assessment Tool – 3rd edition
(SCAT3)
• Symptom evaluation
• Cognitive and physical
evaluation
Cognitive assessment methods:
ImPACT
Immediate Post-Concussion Assesment and Cognitive Testing
• Takes about 30 minutes, 6 testing modules
• Measures attention span and time, working memory, response
variability, non-verbal problem solving and reaction time
• Composite scores for verbal and visual memory, visual motor
speed, reaction time and impulse control
Cognitive assessment:
King-Devick Test (K-D) (King-Devick Test)
• Brief Screening test
• Measures reading speed and saccadic eye movements
Cognitive assessment:
D2-R: Test of Attention (Hogrefe 2016)
• Measures sustained attention, focused attention, selective
attention
• Computer based test
• 5 - 10 minutes
Cognitive assessment:
ATTEX for self evaluation (Klenberg et al. 2010)
(The Attention and Executive Function Rating Inventory)
55 questions
• Distractibility, Impulsivity and Motor hyperactivity
• Directing attention, Sustaining attention and Shifting attention
• Initiative, Planning, Execution of action and Evaluation
Cognitive functioning at baseline 2015 – 2016
ImPACT Composite Scores
100
90
83
78
80
73
67
70
60
50
35
40
32
30
20
10
0
1
2
Sarja1
3
Sarja2
Cognitive functioning at baseline
ImPACT Composite Scores
12
9,5
10
8,7
8
6,9
6,8
6
4
2
0,65
0,63
0
1
2
Sarja1
3
Sarja2
Interventions after Concussion
• Rest
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Definition?
Duration? (Scneider, Iverson, Emery, McCrory, Herring & Meeuwisse 2013)
• Return to school/learn (Halstead et al. 2013, McGrant 2010)
• Return to play (McCrory et al. 2013)
Return to Activity After Military mTBI: guideline
(McCulloch et al. 2015)
Activity progression after mTBI: cognitive aspect
(McCulloch et al. 2015)
Rehabilitation stage
Description of stage
Objective(s)
1 - Rest
Physical and cognitive rest. No videogames, study, driving.
Limit activity to promote
recovery
2 - Light routine activity Cognitive activity for 30 min, followed by 1 h rest.
Initiate and promote limited
effort in cognitive domain
3 - Light occupationoriented activity
Activity demands not to exceed 60 min periods, followed by
rest. No collision sports/contact, videogames, driving.
Full body, complicated
,coordinated movements.
4 - Moderate activity
Cognitive activity 20 – 40 min, with rest 1:2 ratio
Increase intensity and
complexity of exercise and
cognitive activity.
5 - Intensive activity
Taking part to normal
Cognitive activity up to 50 min. No contact or collision sports. activities with maximum
exertion.
6 - Urestricted activity
No restrictions.
Normal cognitive activities.
Treatment or rehabilitation after an injury
Physical therapy
Psychological
treatment
Medication
Symptoms
Vestibular
Rehabilitation
Exersice
Cognitive rehabilitation after mTBI
• Psychological interventions or behavioural therapy
• Depression or anxiety, pain, insomnia
• Neurocognitive rehabilitation after mTBI (Kaldoja 2015, Leddy et al. 2012,
Ponsford 2005, )
• Problems with attention, memory or executive functioning
Cognitive Intervention: Heads in the Game
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Post-injury assessments, follow up the recovery process
Concussion education
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What is concussion? Symptoms? Recovery?
Emotional support
Gradual return to learn
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Avoiding environments that might provoke symptoms
Rest when needed, explaining what rest means
Shorter school days, allow rest brakes, reduced course load
Extra time in tests and in class assignment completion
Help with homework
Compensatory strategies
Future Prospects
• More research on cognitive rehabilitation
• Web-based methods
Thank you!
For more information:
University of Helsinki, Institute of Behavioural Sciences
Heads in the Game
Project coordinator, PhD Student Kati Peltonen
[email protected]
Project planner, Matti Vartiainen
Director, Laura Hokkanen
References
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Halstead ME, McAvoy K, Devore CD, Carl R, Lee M & Logan K. Returning to Learning Following a Concussion. Pediatrics 2013, 132 (5):
948-957.
Harmon K, Drezner J, Gammons M, Guskiewicz K, Halstead M, Herring S et al. Medical Society for Sports Medicine position statement:
concussion in sport. Br J Sports Med 2013;47:15–26.
Kaldoja M-L. Mild traumatic brain injury in childhood: pre-injury social-emotional behavior, social-emotional and cognitive outcome and
implications for attention rehabilitation. 2015, University of Tarto.
Klenberg L, Jämsä S, Häyrinen T, Lahti-Nuuttila P & Korkman M. The Attention and Executive Function Rating Inventory
(ATTEX):Psychometric properties and clinical utility in diagnosing ADHD subtypes. Scandinavian Journal of Psychology 2010, 51, 439–448.
Leddy J, Sandhu H, Sodhi V, Baker J & Willer B. Rehabilitation of Concussion and post-concussion Syndrome. Sports Health 2012; 4(2);
147-154.
McCulloch K, Goldman S, Lowe L, Radomski M V, Reynolds J, Shapiro R & West T A. Development of Clinical Recommendations for
Progressive Return to Activity After Military Mild Traumatic Brain Injury: Guidance for Rehabilitation Providers. J Head Trauma Rehab
2015; 30(1): 56-67.
McGrath N. Supporting the Student-Athlete’s Return to the Classroom After a Sport-Related Concussion. Journal of Athletic Training
2010;45(5):492–498.
McCrory P, Meeuwisse W, Aubry M, Cantu, Dvořák J, Echemendia R. et al. Consensus statement on concussion in sport: the 4th
International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258.
Ponsford J. Rehabilitation interventions after mild head injury. Current Opinion in Neurology 2005, 18: 692-697.
Schneider K J, Iverson G L, Emery C A, McCrory P, Herring S A & Meeuwisse W H. The effect of rest and treatment following sportrelated concussion: a systemic review of the literature. Br Sports Med 2013; 47: 304-307.