Cognitive-linguistic correlates in Athletes and Soldiers

Transcription

1 Cognitive-linguistic correlates in Athletes and Soldiers Bess Sirmon Fjordbak, PhD, CCC-SLP Anthony P. Salvatore, PhD, CCC-SLP, BC-ANCDS Edina R. Bene, PhD University of Texas at El Paso 1

2 Neurometabolic and physical changes that occur in the brain secondary to a jarring movement or external blow to the body or head. 2

3 Deficits observed after a concussion can involve cognitive-linguistic changes such as: impaired concentration decreased processing speed anomia global deficiencies in executive function. 3

4 For athletes, the injury can be sustained from a direct hit, or a jarring motion when hitting the ground or court surface. Among active-duty Soldiers, the injury may also occur from a pressure wave from close-range explosive blasts. 4

5 Lew et al (2007) called for a team approach across the federal agencies to care for Soldiers with TBI given the coexistence of medical and psychological issues in this population. 5

6 McCrea et al. (2003) describe post-concussion deficits in cognitive processing and verbal memory among collegiate athletes, and Kennedy et al. (2007) describe similar patterns among Soldiers. 6

7 exposure to a traumatizing event subsequent re-experiencing of the event with: disruptions in sleep patterns changes in arousal alterations in cognitive processing (Kennedy, et al, 2007) 7

8 Although recognized as prevalent, variability in rates of PTSD among returning Soldiers is reported as ranging from <2% to >30% of that population. (Sundin et al., 2010) 8

9 References to PTSD among post-concussed athletes were not located in a search of the literature. 9

10 We know that in MVA patients there is a positive correlation of post-concussion symptoms and PTSD symptoms. (Bryant et al., 1999) What is the relationship between post-concussion symptoms and PTSD symptoms in Soldiers and Athletes? 10

11 Similarities between Concussion and PTSD cognitive and neuro-vegetative complications decreased attention and concentration decreased accuracy in memory function impaired learning slowed processing speed headache sleep disturbances increased irritability (cf., Chan, 2001; Kennedy, et al., 2007). 11

12 Similarities between Concussion and PTSD Schneiderman et al. (2008) surveyed over 2200 post-deployment veterans, and reported that the most commonly occurring symptoms in both concussion and PTSD were sleep disruptions and increased irritability. 12

13 Similarities between Concussion and PTSD On the other hand Hoge, Goldberg and Castro (2009) suggested that the post-concussive sequelae may be related to other factors, including acute stress, sleep deprivation, or other injuries, and indicated that the symptoms attributed to post-concussive deficits may be more closely related to PTSD or depression. 13

14 What is the relationship between concussion and reported symptoms of PTSD between athletes and Soldiers? 14

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16 Methodology: Population Soldiers collaborative study with the research team at the William Beaumont Army Medical Center, assessing cognitive function in post-deployment Soldiers experiencing chronic headache. 16 Soldiers sustained concussive injuries as a result of IED blast during active duty assignments, and were seen for data collection 12 months postinjury. 16

17 PTSD Questions 1. Are you having nightmares? 2. Are you having flashbacks? 3. Are you having trouble keeping thoughts of the incident out of your head? 4. Are you feeling numb or detached? 5. Are you avoiding similar situations? 6. Are you having difficulty sleeping? Pts were asked to respond yes or no to each of these questions. A yes response equals a score of 1 for the specific question. 17

18 Results: Performance on PTSD Questions Soldiers (n = 16) Time Post Onset 1 yr Mean score = 3.75 SD =

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20 Methodology: Populations Soldiers 7 from the previous cohort Athletes From a larger sample of collegiate athletes seen at the Concussion Management Clinic at the University of Texas at El Paso, 9 were selected from a larger sample, matched as closely as possible to the sample of Soldiers. The data used for comparison in this investigation is from athletes first post-concussion assessment. 20

21 Methodology: Procedures The ImPACT test ( was administered to both samples of Athletes and Soldiers. The ImPACT measures short and long term memory across single words and abstract visual stimuli in addition to assessing learning. The Soldiers were administered the military version which asks questions about the presence or absence of PTSD symptoms. No pre-deployment data was available. The Athletes took the standard version of the ImPACT test. 21

22 Nota bene The second study is based on small convenience samples, and will be reported as a descriptive study. These samples were matched as closely as possible for age, gender and education. 22

23 Athletes Soldiers N 9 7 Gender M = 6 M = 7 F = 3 F = 0 Age Mean sd Education Mean sd Time Post Mean Days 7.2 Mean Months 14.4 # of Concussions Mean sd

24 Athletes Soldiers Memory Composite Verbal Mean 79.56% > 67.43% sd Visual Mean 64.33% > 58.43% sd Reaction Time Mean.63 sec.66 sec sd Total Symptom Score Mean 19.9 < 53.3 sd

25 Analysis of performance on the ImPACT and the Total Symptom Score indicated differences between the Soldiers and matching sample of athletes. One year post-injury, the Soldiers demonstrated impairments in cognitive-linguistic function, and higher ratings on the Total Symptom Score than did the athletes. The athletes who were seen 2 weeks post-concussion, reported significantly fewer indicators on the Total Symptom Score. (Salvatore, Sirmon Fjordbak, Bene, Ponce de Leon, & Prue-Owens, 2008) 25

26 The next section reports PTSD and Symptom data collected from Athletes assessed at the UTEP Concussion Management Clinic 26

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28 Relationship between Post-Concussion and PTSD Symptoms Preliminary investigation showed that Soldiers had significantly higher Symptom Scores than Athletes. Soldiers also reported a number of PTSD symptoms, but at the time of the first two studies, we did not have data on self-reported PTSD symptoms in Athletes. 28

29 PTSD Questions 1. Are you having nightmares? 2. Are you having flashbacks? 3. Are you having trouble keeping thoughts of the incident out of your head? 4. Are you feeling numb or detached? 5. Are you avoiding similar situations? 6. Are you having difficulty sleeping? Pts were asked to respond yes or no to each of these questions. A yes response equals a score of 1 for the specific question. 29

30 RESULTS Athletes self-reported positive responses to PTSD questions at Baseline (n = 145) Mean =.28 SD =.93 Range = 0-6 This mean of.28 is similar to the mean of.44 reported by the sample of 9 concussed athletes at baseline. 30

31 At baseline, this sample of 145 athletes reported an average of less than 1 positive response to the six PTSD questions (mean =.28). This measure would provide some insight into the frequency of free-floating self-reported PTSD symptoms in athletes prior to a concussion. 31

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33 Methodology Pre-participation baseline data was collected, with follow-up testing after sustaining a concussion in either practice or play. Athletes were seen for serial re-assessment of cognitive-linguistic function for the purpose of monitoring recovery and contributing to return-to-play decisions. 33

34 We looked at our data on athletes who were tested after concussion, and found that while they reported symptoms of PTSD immediately following the concussion, over the course of recovery, these self-reported symptoms of PTSD diminished. 34

35 RESULTS Post-Concussed Athletes self-reported PTSD symptoms over time: BL PC-1 PC-2 PC-3 N Mean SD

36 RESULTS A sample of post-concussed athletes shows a significant reduction in self-reported PTSD symptoms from Post-Concussion 1 to Post-Concussion 2 to Post- Concussion 3 on serial re-assessment. We only had BL-PTSD data on 9 of 85 athletes who eventually suffered a concussion. So, there is PTSD data on 76 athletes who suffered a concussion, but for whom we had no BL data. 36

37 RESULTS Post-concussion, athletes showed a reduction in positive responses to the PTSD questions from PC1 through PC3. The average number of PTSD symptoms for the baseline data (.28) is less than the average reported (1.3) at PC-1. However, the athletes showed increase in self-reported PTSD symptoms after concussion from.44 to 1.3. As a point of comparison, Soldiers reported a mean of 3.35 PTSD symptoms at one year post-concussion. 37

38 When comparing Soldiers and athletes diagnosed with concussion, the manifestations are substantially different, including presence and frequency of co-morbid Total Symptom Score and selfreported PTSD symptoms. 38

39 Differences: cause of the injury (hit versus blast) the etiological and localization manifestations (focal versus global) history of previous concussion/mtbi context within which the injury was sustained (sport versus war). 39

40 Baseline data showed that athletes show few pre-morbid signs of PTSD. Additional analysis showed that athletes do not show persistent signs of PTSD post-concussion. 40

41 Both the athletes and Soldiers reported concussion. The two groups differed in terms of Total Symptom Score and response to PTSD questions. Soldiers at 1 year post-concussion/mtbi report higher Total Symptom Scores, and respond affirmatively to questions assessing the presence or absence of PTSD symptoms. 41

42 This data suggests that while the nature of the injury to the brain is different in many cases between the athletes and the Soldiers, specific indicators of the pre-morbid presence of PTSD symptoms in Soldiers is needed before any definitive conclusion can be made about the correlation between cognitive linguistic performance and PTSD symptoms between athletes and Soldiers who have experienced concussion. 42

43 The comparison points out: Even many months removed from the battlefield, the Soldiers continued to present with cognitivelinguistic deficit profiles that were still more impaired than those observed in athletes who were seen within a few days of their injury. 43

44 The comparison points out: When compared to soldiers, the athletes did not report a comparable number of PTSD symptoms. in general, performance on measures of cognitivelinguistic function were qualitatively and quantitatively different. most athletes recovered within two to three weeks with appropriate care. 44

45 The controversy surrounding the frequently co-morbid diagnoses of PTSD and concussion remains unresolved. The data from the athletes suggests that the occurrence of a concussion does not necessarily lead to persistent symptoms of PTSD. Hoge et al. (2009) advocate for improved assessment instruments, replacing the diagnosis of mtbi with concussion, in an effort to prevent disability classification based on inadequate evidence. 45

46 Schneiderman and colleagues (2008) suggest that PTSD should be considered along a spectrum of mild, moderate, severe, in conjunction with descriptive ratings of concussion injuries. Such classifications will lead to more accuracy in differential diagnosis, as the label of concussion alone may not be sufficient to describe the range of injuries, comorbid diagnoses, and diversity of recovery patterns observed in clinical settings. 46

47 Limitations: One of the significant differences between the original two groups was the amount of time post-injury at the time of measurement. Small sample sizes Lack of comparable baseline data for both samples. 47

48 Acknowledgments Thanks to William Beaumont Army Medical Center for their cooperation in this project. We are grateful to Lt Col Kathy Prue-Owens and her research team for involving us in their work, and to Dawn Hearn, ATC and the UTEP Athletic Department for their support of the Concussion Management Clinic. SLP graduate students: Jackie Picone, Vanessa Fernandez, and Attea Guidi. Sincere gratitude is extended to all the participants. 48

49 Chan, RCK (2001). Base rate of post-concussion symptoms among normal people and its neuropsychological correlates. Clinical Rehabilitation, Vol 15(3), Hoge, CW, McGurk, D, Thomas, JL, Cox, AL, Engle, CC & Castro, CA (2008). Mild Traumatic Brain Injury in U.S Soldiers Returning from Iraq, New England Journal of Medicine. 358 (5), ImPACT website; Kennedy, JE, Jaffee, MS, Leskin, GA, Stokes, JW, Leal, F, Fitspatrick, PJ (2007). Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and mild traumatic brain injury. J Rehabilitation Research & Development, 44, Lew, HL, Poole, JH, Vanderploeg, RD, Goodrich, GL, Dekelboum, S, Guillory, SB, Sigford, B, Cifu, DX. (2007). Program development and defining characteristics of returning military in a VA Polytrauma Network Site, Journal of Rehabilitation Research & Development, 44 (7),

50 McCrea, M, Guskiewicz, KM, Marshall, SW, et.al. Acute effects and recovery time following concussion in collegiate football players: The NCAA Concussion Study, JAMA 2003, 290, Salvatore, A. P., Sirmon Fjordbak, B., Bene, E.R., Ponce de Leon, M., & Prue-Owens, K. (2008, July). Comparison of concussion in athletes and soldiers. Poster session presented at New Developments in Sports-Related Concussion Conference. Pittsburgh, PA. Schneidermann, AI, Braver, ER, Kang, HK. (2008). Understanding Sequelae of Injury Mechanisms and Mild Traumatic Brain Injury Incurred during the Conflicts in Iraq and Afghanistan: Persistent Postconcussive Symptoms and Posttraumatic Stress Disorder, Am. J. Epidemiol. (2008) 167 (12): Sundin, J., Fear, NT, et al., (2010). Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, Vol 40(3),