Recovery Factors after Concussion: Clinical Considerations

Orli Shulein, MS, CCC-SLP

Introduction

• Employers

– Harborview Medical Center

– Neuropsychology and Cognitive Health

• Clinical interests and experience

• Disclaimer

– Not a researcher

Goals

• Understand the “miserable minority”

• Examine theoretical factors that may influence recovery

• Learn how those factors are clinically relevant

– Cognitive rehab

– Primary care providers

TBI Severity Ratings

Severity GCS AOC LOC PTA

Mild 13-15 ≤24 hrs 0-30 min ≤24 hrs

Moderate 9-12 >24 hrs >30 min <24 hrs

>24 hrs <7 days

Severe 3-8 >24 hrs ≥24 hrs ≥7 days

GCS Glasgow Coma Scale AOC Alteration of consciousness LOC Loss of consciousness PTA Post-traumatic amnesia Veteran Affairs Mild Traumatic Brain Injury Pocket Guide for Clinicians (2010).Retrieved from : http://www.publichealth.va.gov/docs/exposures/TBI-pocketcard.pdf

“Miserable Minority”

• Who sees these patients?

“Miserable Minority”

• Term coined by Ruff and colleagues in mid 1990s (Ruff et al., 1994; Ruff, Camenzuli, & Mueller, 1996; Ruff, 1999)

• Patients who:

– Suffer a concussion

– Do not recover 3 months post-injury

– Estimated to be ~15% of patients (Wood, 2004)

“Miserable Minority”

• Assumes multiple causes for an incomplete recovery

– Neuropathology

– Psychopathology

– Pre-existing vulnerabilities

– Secondary gain

– Often there is a combination….

“Miserable Minority”

• Who are these patients?

• Literature varies…. (Hoffman et al., 2012; Lee, Garber &

Zamorski, 2015; Rabinowitz et al., 2015; Silverberg et al., 2015; Stulemeijer et al., 2008; Dischinger et al., 2009; Tator et al, 2016; Zuckerman et al, 2014; Theadom et al., 2016)

“Miserable Minority”

• Women • Premorbid mental health history • Non-white • Lower education level • Older age • History of prior TBI • History of migraines • History of ADHD/ learning disability • Involved in litigation • Extracranial injuries • Alcohol and medication usage • Amnesia or +LOC

The Debate

• Acknowledge it

• Is the DEBATE clinically relevant?

For now…let’s agree that there are multiple factors driving recovery.

Recovery Factors: Theoretical

• Patient factors

– Pathophysiologic

– Psychosocial

• Iatrogenic factors

Pathophysiologic

– Wood (2004) provides an overview of some pathophysiologic changes

– Dixon & Hayes (1995) and Polvishock (1995) showed in MTBI evidence of • Microscopic and hemorrhagic lesions • Neuronal loss and chromatolysis • Axonal damage

– Polvishock & Coburn (1989): Early axonal changes would compromise metabolic integrity of neurons

– Hattori et al. (2009) found frontocerebellar disassociation in MTBI patient using SPECT scans while performing the PASAT • Argued it could contribute to cognitive issues and fatigue

Psychosocial

• Illness perception

• Misattribution effects

• Emotion & cognition

• Others…

Illness Perception

• Illness Perception

– Can pre-held beliefs about illness impact recovery?

• Diagnosis threat

• Illness belief

Illness Perception

• Diagnosis threat (Suhr & Gunstad, 2002 & 2005)

– Pre-held stereotypes about how one should perform with a specific injury

– Based on stereotype threat

• Cognitive testing from low SES backgrounds

• Math skills in women

• Memory in older adults

Illness Perception

• Diagnosis threat (Suhr and Gunstad, 2002 & 2005)

– Undergrad students with prior MTBI history were randomized in diagnosis threat and neutral groups

• No litigation

• All volunteers

– Students who received instructions that highlighted the possibility of cognitive impairment following MTBI did worse on cognitive tests

Illness Perception

• Diagnosis threat (Carter-Allison, Potter & Rimes, 2016)

– Replicated Suhr and Gundstad’s studies with adult, amateur boxer & rugby players

• Excluded if mTBI was less than 3 months ago

• Excluded if in litigation or treatment

– No difference on performance on cognitive tests between subjects in the diagnosis threat and neutral groups

Illness Perception

• Why the differing outcomes?

– Perhaps different illness beliefs between groups?

Illness Perception

• Illness belief

– Preexisting beliefs about how bad or debilitating an injury is.

• Authors concluded that

– Athletes may not have “identified with the mTBI stereotype strongly enough to elicit a diagnosis threat response.”

– It may be that illness belief have a harmful effect when “explicitly negative”

Illness Perception

• Big Picture = Preexisting beliefs about injury can perhaps influence how one relates to injury if it occurs

Misattribution Effects

• Misconstruing cognitive, emotional, and physical symptoms as effects of brain injury when they are not (Wood, 2004)

Misattribution Effects

• Post-concussive symptoms have been found in non-TBI populations (Iverson, 2016; Wood, 2004)

– In college students

– Mental health outpatients

– General medical patients

– Chronic pain patients

– Personal injury litigants

– Sleep disturbance

– Chronic disengagement

Misattribution Effects

• Big Picture =

– Patients may not be accurate self reporters of symptoms as they relate to injury versus other causes.

– Cognitive complaints are sensitive but not specific

Emotion & Cognition

• Studies have suggested (Wood, 2004)

– Anxiety can decrease attention and working memory

– Depression may be associated with impaired memory function

• Many patients with lasting post-concussive symptoms suffer from anxiety and/or depression.

Emotion & Cognition

• Big picture = Whether a patient has premorbid or comorbid anxiety and/or depression, these will still impact their underlying cognitive function

Iatrogenic Effects

• “Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.”

• Healthcare • Litigation • Media Iatrogenic. (n.d.). In Merriam Webster online. Retrieved from https://www.merriam-webster.com/dictionary/iatrogenic

Healthcare

• What I hear from patients: – “My doctor said I would get better in a few weeks

and I’m still not better.”

– “They didn’t do anything for me when I went to the hospital.”

– “No one told me I had a concussion until months later. I lost so much time.”

– “I’ll be brain injured for the rest of my life.”

– “I have a severe TBI.”

– “I have a severe concussion.”

Healthcare

Are we part of the problem?

Communication

• Primary care providers are often the first point of contact.

• You may influence how they cope and perceive their symptoms

• Dismissing symptoms as “psychological” can lead to misattribution and alienation

• Overly empathic support can reinforce illness perceptions.

Terminology

• Terminology can reinforce illness perception

– Concussion v. mild traumatic brain injury

– Some patients feel that all of their problems are permanent

• Certain disciplines do the above more if they are unfamiliar with the population

Symptom Diaries

• Symptom diaries can heighten illness perception for some

– Can heighten their awareness of symptoms

– May bias perception of normal brain & body reactions

Support Groups

• Support groups

– If not run by experienced healthcare workers or if run by lay people

– Can entrench misperceptions and misinformation

Clinical Considerations

Cognitive Remediation

• General therapy techniques

– Compensatory strategies

– Impairment level treatment

– Metacognitive treatment

Cognitive Remediation

• Under 6 months post-injury

– Misattributions may or may not be present

– Continue to strongly reinforce prospect of FULL RECOVERY

– Goal =

1. Support with practical compensatory systems

2. Train subthreshold functioning

3. Validate concerns but don’t hyperfocus on issues

Cognitive Remediation

• 6 months to 12 months post-injury

– Increased emotional component likely

– Misattributions developing?

– Continue to reinforce possibility for a full recovery

– Goals:

1. Educate ALL factors influencing continued cognitive dysfunction.

2. Provide power to alleviate symptoms via strategies and metacognition.

3. Squash misattributions as they occur

Cognitive Remediation

• Greater than 1 year post-injury

– Emotional component likely pronounced

– Misattributions may be entrenched

– Functional recovery is emphasized

– Goal:

1. Challenge misattributions while building confidence in one’s own cognitive abilities.

2. Treatment may be more hyper focused on certain cognitive modalities to challenge beliefs.

Primary Care Providers

• Consider the demographics of those that do not recover

• Educate about what a concussion is and is NOT

• Educate about current gold standard concussion care

• Don’t over or under-emphasize cognitive symptoms.

• Focus on anticipated recovery

Primary Care Providers

• Recognize that patients often are not clear about what is driving their cognitive issues – i.e. Cognitive issues that arise 1 year AFTER a

concussion are not secondary to a concussion

• Help patients understand that the brain is not static so recovery will not be static

• Help patients to stay engaged in their lives – Chronic disengagement longer term disability

– Educate about subthreshold effort

Primary Care Providers

• Your words have power & can provide patients a sense of control:

– Mild TBI can mean permanent damage to some

– Sleep, mood, pain disturbances are things people can work on

Primary Care Providers

• Develop a list of referral sources that specialize in working with this population

– Psychotherapists

– Neuropsychologists

– Speech-Language Pathologists

– Vocational Rehab Counselors

– Physical Therapists

– Neurologists/ Physiatrists

Primary Care Providers

Manage the symptoms while simultaneously validating the patient’s experience, challenging

misattributions, and referring to specialty providers.

Thank you

References • Carter-Allison, S.N., Potter, S., Rimes, K. (2016). Diagnosis threat and injury beliefs after mild traumatic brain injury.

Archives of Clinical Neuropsychology, 31, 727-737.

• Dischinger P.C., Ryb, G..E, Kufera , J.A., Auman, K.M. (2009). Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. J Trauma 2, 66, 289-97.

• Dixon, C.E & Hayes, R.L. (1995). Fluid percussion and cortical impact models of traumatic brain injury. In R. K. Narayan, J. E. Wilberger and J. T. Povlishock (Eds.), Neurotrauma (pp. 1337–1346). New York: McGraw-Hill.

• Hattori, N., Swan, M., Stobbe, G.A., Uomoto, J.M., Minoshima, S., Djang, D., Krishnananthan, R., & Lewis, D.H. (2009). Differential SPECT activation patterns associated with pasat performance may indicate frontocerebellar functional dissociation in chronic mild traumatic brain injury. The Journal Of Nuclear Medicine , 50 (7), 1054-1061.

• Hoffman JM, Dikmen S, Temkin N, Bell KR. (2012). Development of posttraumatic stress disorder after mild traumatic brain injury. Archives of Physical Medicine & Rehabilitation, 93, 287-92

• Iverson, G.L (2016). Understanding and treating post-concussion syndrome [PowerPoint slides]. Retrieved from http://nan.informz.net/NAN/data/images/2016%20NANSNS%20Symposium/Understanding%20and%20Treating%20PCS-Slides-Iverson-Vancouver.pdf.

• Lee, J., Garber , B., Zamorski, M. (2015). Prospective Analysis of Premilitary Mental Health, Somatic Symptoms, and Postdeployment Postconcussive Symptoms. Psychosomatic medicine, 77(9), 1006-1017

• Povlishock, J.T. (1995). An overview of brain injury models. In R. K. Narayan, J. E. Wilberger and J. T. Povlishock (Eds.), Neurotrauma (pp. 1337–1346). New York: McGraw-Hill.

• Povlishock, J.T. & Coburn, T.H (1989). Morphopathological change associated with mild head injury. In H. S. Levin, H. N. Eisenberg and A. L. Benson (Eds.), Mild Head Injury (pp. 37–53). New York: Oxford University Press.

References

• Rabinowitz, A., Li, X, McCauley, S., Wilde E.A., Barnes, A., Hanten, G., Mendez, D., McCarthy, J.J., & Levin, H.S, (2015). Prevalence and Predictors of Poor Recovery from Mild Traumatic Brain Injury. Journal of Neurotrauma, September, 32(19): 1488-1496.

• Ruff, R.M. (1999). Discipline specific approach vs. individual care. In N.R. Varney and R.J. Roberts (Eds.), Mild Head Injury: Causes, Evaluation and Treatment (Chapter 7, 99-113). Mahwah, New Jersey: L. Erlbaum Associates.

• Ruff, R.M., Camenzuli, L., & Mueller, J. (1996). Miserable minority: Emotional risk factors that influence the outcome of a mild traumatic brain injury. Brain Injury, 10, 551–565.

• Ruff, R.M., Crouch, J. A., Troster, A. I., Marshall, L. F., Buchsbaum, M. S., Lottenberg, S., et al. (1994). Selected cases of poor outcome following a minor brain trauma: Comparing neuropsychological and positron emission tomography assessment. Brain Injury, 8, 297–308.

• Silverberg, N. , Gardner,A, Brubacher, J.R., Panenka, W.J, Li, J.J., & Iverson, G.L., (2015). Systematic Review of Multivariable Prognostic Models for Mild Traumatic Brain Injury. Journal of Neurotrauma, 32, 517–526.

• Stulemeijer, M., Van der Werf, S., Borm, G.F. & Vos, P.E. (2008). Early prediction of favourable recovery 6 months after mild traumatic brain injury. J Neurol Neurosurg Psychiatry, 79, 936–942.

• Suhr, J. A., & Gunstad, J. (2002). ‘‘Diagnosis threat’’: The effect of negative expectations on cognitive performance in head injury. Journal of Clinical and Experimental Neuropsychology, 24, 448–457.

• Suhr, J. A., & Gunstad, J. (2005). Further exploration of the effect of ‘‘diagnosis threat’’ on cognitive performance in individuals with mild head injury. Journal of the International Neuropsychological Society, 11, 23–29

• Tator, C.H., Davis, H.S., Dufort, P.A., Tartaglia, M. C. , Davis, K.D., Ebraheem, A. & Carmen, H. (2016). Postconcussion syndrome: demographics and predictors in 221 patients. Journal of neurosurgery, 125(5), 1206-1216.

• Theadom, A., Parag, V., Dowell, T., McPherson, K., Starkey, N., Barker-Collo, S., Jones, K., Ameratunga, S., & Feigin, V.L. (2016)., Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. British Journal of General Practice, Jan, 66(642), 16-23.

References

• Vanderploeg , R.D, Belanger, H.G, & Kaufmann, P.M. (2014). Nocebo effects and mild traumatic brain injury: legal implications. Psychol. Inj. and Law, 7, 245–254.

• Wood, R.L. (2004). Understanding the miserable minority: a diasthesis-stress paradigm for post-concussional syndrome, Brain Injury , 18 ,1135–1153.

• Zuckerman, S.J, Apple, R.P, Odom, M.J., Lee, Y.M, Solomon, G.S., & Sills, A.K. (2014). Effect of sex on symptoms and return to baseline in sport-related concussion., Journal of neurosurgery, 13(1), 72-81.