Psychosocial Components of Concussion Management

Transcription

1 Psychosocial Components of Concussion Management Stephen A. Russo, Ph.D. Clinical Sport Psychologist Concussion Management Specialist Jefferson Comprehensive Concussion Center Thomas Jefferson University

2 Lecture Objectives Outline Current Social and Cultural Dynamics of Sport Participation Highlight How a Health Psychology Paradigm can Help Clinicians Understand Concussion Reporting and Athletes Compliance Practices with Medical Professionals Demonstrate How Psychosocial Components of Athletics Can Influence Concussion Recovery after Injury

3 Injuries are A Natural Consequence of Sports Estimates of Kids playing Sports: 60 Million children (6-18) participate in some form of organized activity 27 Million children participate in team sports 44 Million children play more than 1 sport Overuse Injuries Acute / Traumatic Injuries Limits Functioning the Following Day or Requires Professional Medical Attention (e.g., Licensed Athletic Trainer, Physician, ER Visit) Due To Repeated Stress To The Body Combined with Insufficient Rest That Is Needed for the Body to Heal

4 Acute / Traumatic Injuries In 2012, sports injuries resulted in over $935 Million in medical costs for ED visits. Injuries were usually due to player contact (58% in competition; 42% in practices) and more than 50% of injuries occur in lower extremities

5 The Culture of Youth Athletics Douglas Brunt Time Magazine; May, 2017 Money is Ruining Youth Sports Sports No Longer a Prize unto Itself! As it Becomes More about College Scholarships, Generational Wealth, and Glamorous Lifestyles, Parents Get Destination-obsessed. A 2015 NPR Survey (w/ The Robert Wood Johnson Foundation and Harvard's T.H. Chan School of Public Health) Showed a Correlation between Socioeconomic Status and Parental Hope for Professional Sports. 9% of Parents with College Degree Want Kids To Be Professional Athletes 44% of Parents with less than a High-School Degree Want Pro-Athlete Kids.

6 Familial Expectations for NCAA Football Players

7 HS to NCAA Statistics: Men s Sports

8 HS to NCAA Statistics: Women s Sports

9 NCAA Statistics: Going Pro

10 The Culture of Youth Athletics Douglas Brunt Time Magazine; May, 2017 Money is Ruining Youth Sports The Educational Component of Sports Is Diminishing, and the Prevailing Mindset for Success in College Admissions has Become Sport Specialization Societal Pressure to Force Kids into Early Specialization Actually Narrows Development of Children and Extends the Dynamic of "Haves and Have-Nots" Dedication, Time, and Money Required to Play Athletics Year-Round is far Beyond what American Youth Experienced in Previous Decades Intensity of Training has Led to a Cottage Industry of Extra Coaching Other Pursuits (e.g., Music, Art) Have Also Adopted Specialization Approach. Kids are Not Just Picking One Sport at the Expense of Other Sports. They re Picking One Sport at the Expense of any other Kind of Life!!

11 Pre-College Specialization in Athletics

12 The Culture of Youth Athletics Jacob Bogage Washington Post; Jan, 2017 Sport Specialization Increases Injury Risk For HS Athletes, Study Finds Surveyed 1,544 Athletes in Wisconsin and Tracked Lower-Extremity Injuries More than 40% of Female Athletes and 28% of Male Athletes Were Specializing. Study Found Athletes who Specialized Suffered Injuries At Significantly Higher Rates HS Athletes who Specialize were 70% More Likely to Suffer an Injury During Their Playing Season than Those Who Play Multiple Sports. Muscle or Ligament Sprains Were Most Commonly Reported Injuries. Ankle or Knee Injuries Accounted for 59.4% of Injuries Reported Specialized Athletes who Play or Train for their Sport Year-Round are More Susceptible to Injury Because They are EXPOSED to their Sport More Often and Put More Stress on the Concentrated Group of Muscles, Ligaments and Bones Related to their Sport (i.e., OVERTRAINED ).

13 Sport Specialization for Youth Sports: Females

14 Sport Specialization for Youth Sports: Males

15 Predictor of Overuse Injuries: Training volume Injury rates in high school athletes have a direct relationship to exposure by hours per week and higher training intensity / volumes have consistently been shown to increase the risk of overuse injuries. Weekly Volume Training more than 16 hours a week was associated with a significantly increased risk of overuse injury Scheduling Multiple events on same day or several over consecutive days is considered as a risk factor for overuse injuries Yearly Volume Kids (9-14) who pitched more than 100 innings a year were 3.5 times more likely to suffer an overuse injury Injury Yearly Volume There is an increased risk for shoulder and elbow injuries for youth pitchers who pitch more than 8 months a year. Yearly Volume There was 42% increase in overuse injuries in high school athletes who participated all year versus 3 seasons or less per year

16 The Current Culture of Adolescence Susanna Schrobsdorff Time Magazine; Oct., 2016 Teen Depression and Anxiety: Why the Kids Are Not Alright Today s Adolescents are a Post-9/11 Generation, Raised in an Era of Economic / National Insecurity Never Known a Time when Terrorism and School Shootings Weren't the Norm. Grew Up Watching Their Parents Weather a Severe Recession Hit Puberty when Technology and Social Media Were Transforming Society. A 2015 CNN Special Report (Conducted with Researchers at the University of California, Davis and the University of Texas at Dallas) Examined Social-Media Use of More than year-olds. Authors Found there was "No Firm Line between Real and Online Worlds. Technology And Online Bullying Are Affecting Kids As Early As Fifth Grade. Standardized Testing Protocols Implemented In The Past Decade Now Have Tests Running From January Through May Being a Teenager Today is a Draining, Full-time Job Doing Schoolwork Managing a Social-Media Identity Fretting about Cultural and Societal Pressures Every Fight / Slight is Documented Online for Hours or Days after the Incident.

17 The Current Culture of Adolescence Susanna Schrobsdorff Time Magazine; Oct., 2016 Teen Depression and Anxiety: Why the Kids Are Not Alright Anxiety and Depression in High School Kids Have Been on the Rise Since 2012 Statistic Cuts Across All Demographics - Suburban, Urban And Rural Mental Illness Impacts Those Who Are College Bound And Those Who Aren t Family Financial Stress Can Exacerbate These Issues Studies Show That Girls Are More At Risk Than Boys. In 2015, HHS Reported that about 3 Million Teens (Ages 12-17) Experienced at Least One Major Depressive Episode in the Preceding Year More Than 2 Million Report Experiencing Depression that Impairs Daily Function. According to the NIMH, about 30% of Girls and 20% of Boys (Almost 6.3 Million Teens) Have Had an Anxiety Disorder Child Mind Institute Found in 2015 that only about 20% of Young People with a Diagnosable Anxiety Disorder Get Treatment.

18 The Current Culture of Adolescence Susanna Schrobsdorff Time Magazine; Oct., 2016 Teen Depression and Anxiety: Why the Kids Are Not Alright

19 Student Athletes and Stress Issues Such as Pressure to Perform, Time-constraints, High Training Volumes, and Limited Sleep Exemplify Their Heightened Stress Levels. College Student-Athletes Experience More Psychological Pressure and Stress than their Non-Athletic peers, But are Significantly Less Likely to Seek Mental Health Services. When Student-Athletes Seek Counseling, They Have More Stress-Related Physical Illnesses and Higher Rates of Depression and Anxiety. Examination of Student-Athlete Sleep Patterns Show they Experience, on Average, Four Nights of Insufficient Sleep per Week.

20 Physical / Mental Recovery Physical and psychological readiness to return to sports don t always coincide! Cognitions Mood and Emotions Motivation Due to the social nature of rehabilitation, mental factors can also influence the physical outcome / response to injury Social Support Athletic Identity Recovery Self-Efficacy Trust in Treatment

21 Factors Associated with Rehabilitation Outcomes Injury-Related Emotions Injury-Related Thoughts Injury-Related Behaviors Research has found that emotional reactions that follow the occurrence of injury can have an impact on the outcome of rehabilitation. Injury-related cognitions can influence mood and emotions. Research has shown that personal and situational factors that influence thoughts also have an impact on recovery Coping strategies, social interactions, and exercise adherence are all examples of behavior patterns that impact rehabilitation outcomes

22 Emotional Recovery Following Injury Emotional Recovery for Athletes Following Injury is a Dynamic Process Involving Many Factors Where Athletes May Attempt to Play Through Pain, Experience a Loss of Identity and Feeling of Helplessness. Initial Reactions Sources of Stress Challenge, Then Strength Social Support Initial reactions include feelings of negativity, anxiety, isolation, uselessness, guilt, and lack of athletic identity. Factors like position on team, time of season, type of season, and previous injury experience can also influence reactions. Uncertainty about length / extent of rehabilitation, clearance, and readiness to play are evident throughout the recovery process. Feelings of social / team isolation and feeling pressure to prove oneself can negatively impact recovery Mental toughness, hardiness, and optimism have been found to falter right after an injury. Athletes show increased motivation and confidence in their ability to come back as rehabilitation progresses. Social Support, particularly from family, friends, and therapists has a positive effect on an athlete s emotional states. Interacting with people, accepting encouragement, and communicating with treatment team appear to help

23 Injury-Related Emotions Associated with Rehab Outcomes Injury is a Significant Stressor that Athletes are Sometimes Ill-prepared or Unwilling to Face. Injured Athletes are More Likely to Experience Depression, Anxiety, and Reduced Self-esteem when Compared to Their Un-injured Peers Athletes with Lower Self-esteem and Greater Emotional Reactions after Injury Were: Athletes Say that Frustration, Confusion, Anger, and Fear are Common Early Reactions to Injury. However, Negative Emotions Generally Decrease as Rehabilitation Progresses. Emotional Reactions are Not as Fixed or Orderly as Has Been Suggested by Grief Models. Persistent Post-injury Emotional Disturbance Is Associated With: Poor Adherence To Rehabilitation Regimen Poor Rehabilitation Outcome Emotional Distress After Injury Was Also Associated With Decreased Confidence In: A Full Recovery, Success In Sport, Or Ability To Adhere To Rehab Generally more Invested in Playing Professional Sports Had a Greater Identification with Being an Athlete Rarely Had other Interests, Activities, A Reluctance to Discuss Emotions Related to Being Injured with Peers or Coaches Was Associated With: Persistent Feelings Of Isolation And Alienation Athletes Also Have Heightened Fears During The Transition Back To Sport. Commonly Reported Fears Include: Fear Of Re-injury Fear Of Falling Behind Others or Motivations Outside of Sports. Reduced Long-term Fear Of Underperforming Psychological Rehabilitation Fear Of Missing Out

24 Concussion in A Health Psychology Context Psychological Research Confirms That People Do NOT Universally Adopt Healthy Behavior Patterns, Nor Do They Consistently Seek Medical Assistance. Disease Severity is NOT Associated with Treatment Compliance, But Pain and Discomfort Caused by Any Injury or Disease Process DOES Seem to Have a Positive Influence on Treatment Compliance. Seeking Treatment Involves Various Factors, with a Prime Determinant Being the Subjective Experience of Feeling Ill, Rather than the Presence of Injury or Disease That Involves Ongoing Physical Damage to the Body. Failure To Comply With Treatment Recommendations Is Common: Over 125,000 Die Every Year in the US Due to Failure to Follow Medical Advice Average Non-Compliance Rate = 25%. Non-Compliance as High as 50% for Chronic Conditions, Regardless of whether treatment was for Prevention or Cure People Tend To Seek Medical TX Due To: Symptom Characteristics: Are Highly Visible Are Perceived As Being More Serious Interfere With A Person s Life Are Frequent And Persistent UNDERSTANDING OF THE DISEASE: Knowledge of Identity, Etiology, and Course of Disease Understanding of Consequences and Controllability of A Disease.

25 Concussion in A Health Psychology Context Factors Involved in Treatment Compliance Treatment Compliance is Crucial Because There are Large Differences in Outcomes for People who Comply with Treatment Versus Those Who Do Not. People Show Less Adherence to Treatment When: They Dislike or Have Trouble Talking to Their Physicians Have Care Providers with Poor Communication Skills or Little Warmth Have Less Trust, Confidence, and / or Faith In Treatment AGE: Children and Adolescents are Notoriously Poor at Treatment Compliance Less Treatment Compliance Should Be Expected for Disorders and Injuries That Impact This Group. EMOTIONALITY: Mild-to-Moderate Disease-Specific Anxiety Actually Leads to GREATER Compliance Suggesting That Increasing Clients Knowledge of The Potential Negative Effects of An Injury or Disease Are Essential Components of Treatment BELIEFS: Positive Self-Efficacy, A Belief in The Outlined Treatment Plan, and Personal Responsibility Are Associated with Improved Treatment Compliance. SOCIAL SUPPORT: Consistently Found to Help Improve Treatment Adherence. Conversely, Family Conflict Has Been Associated with Reduced Compliance. Rehabilitation Adherence and Outcome is Related to Athlete s Perceptions and Cognitive Appraisals about Treatment Efficacy Those With Faith In Themselves, The Treatment Plan, and the Medical Staff Recovered Faster.

26 Concussion in A Health Psychology Context The Development of any CHRONIC PAIN CONDITION Involves Psychological Factors: Perception of Pain is the Result of Interpretation of the Injury and Its Sensations. Believing a Stimulus is Harmful or Attributing Greater Meaning to Painful Sensations Cause People to Experience More Pain. People Who are Worried, Anxious, Depressed, or Have A Negative Outlook Have a Higher Sensitivity to Pain. Operant Conditioning, Social Reinforcement, and Secondary Gain Issues All Contribute to the Persistence of Pain Behaviors. Factors Associated with a Faster Recovery from Injury Include (1) Maintaining a Positive Attitude and Outlook, (2) Being Self-Motivated and Having the Desire to Heal, (3) Having Social Support in Primary Social Network and Rehabilitation Facility. Pain Intensity is One of the Most Powerful Predictors of Activity Tolerance, Particularly within Rehabilitation, but CATASTROPHIZING is Associated with Higher Levels of Subjective Pain Intensity, Disability, and Emotional Distress. Emotional Distress was also Associated with Cognitive Appraisals (i.e., Thought Patterns) that Lead to Decreased Confidence In: A Full Recovery Success In Sport The Ability To Adhere To The Rehabilitation Process. CATASTROPHIZING is a Way of Thinking about an Injury Where People: Ruminate about Painful Sensations: I Can t Stop Thinking About How Much It Hurts Magnify Values Of Pain Sensations: I Worry Something Serious May Be Wrong Feel Helpless To Cope Effectively: There s Nothing I Can Do About It

27 Concussion in A Health Psychology Context Depression is a common feature of Post- Concussion Syndrome. Although a substantial portion of chronic pain patients suffer from depression, it is difficult to determine a causal direction between emotional disturbance and pain fixation. Female Gender Litigation Restoration of Athletic Ability and Return To Play are primary objectives following any injury, but intersection of health-seeking behaviors and competitive nature of sports makes recovery from concussion more complicated. Fear and Anxiety Can Be Directed at Any or All of the Following: Uncertainty About Clearance Process Uncertainty About Long-term Career Thoughts of Current / Future Health Concerns of Death, Disability, and Reduced Quality-of-Life. Concerns About Maintaining Elite Level of Performance or Intensity Loss of Control, Pride, or Identity by A Forced Alteration of Playing Style. Pre-morbid Psychological Functioning Here are some of the social, psychological, & emotional factors that contribute to the development & maintenance of Post- Concussion Syndrome Pre-morbid Physical Functioning Repeated Concussions Concussion symptoms are typically worst in the first 7-10 days, but usually resolve within the first month following the injury. Severity of the original injury does not directly correlate with the risk of PCS and, often times, PCS symptoms are worse than the initial symptoms.

28 Counseling Interventions for Concussion There is a Significant Positive Association between Appropriate Education, Reassurance, and Provision of Support for the Reduction of PCS Symptoms Clinicians Working in TBI Have Identified Education, Reassurance, Psychological Support, Cognitive Reattribution of Symptoms and Gradual Activation as Being Associated with Better Outcomes. Education Components Range from Providing Information about Concussion Symptoms to Medication Management Issues and an Expected Course of Recovery. Cognitive Training Focuses on Altering the Problematic Beliefs and Helping Clients be Better at Problem-Solving and at Self-Monitoring Their Thoughts, Emotions, and Behaviors Cognitive Interventions such as Retraining Attributions and Cognitive Appraisals Have Been Found to be Successful in Different Populations as well as for Different Areas of Behavior (i.e., Depression, Anger, Fear, etc.). Goals for Treatment Typically Focusing on Increasing Self-Control / Self-Management of Symptoms. Interventions Aimed at Enhancing Cognitive Coping Strategies Have Shown Improvements. Cognitive Approaches in this Area Include Teaching Patients: Mental Disengagement Positive Reinterpretation Emotional Venting And Re-processing Relaxation Training And Guided Imagery

29 THANK YOU Stephen A. Russo, Ph.D. Clinical Sport Psychologist Jefferson Comprehensive Concussion Center Thomas Jefferson University