Emotional Symptoms in Athletes With PCS David Westerdahl, MD FAAFP Cleveland Clinic Florida 6/24/2012
Objectives Discuss Post-Concussion symptoms and functional problems Identify pre-injury factors that may lead to poor outcome from a concussion Discuss treatment of emotional symptoms related to mtbi
Invisible Injuries Concussion/mTBI and PTSD Recent wars have focused attention on mtbi and PTSD in unprecedented ways Prevalence of US military in OEF and OIF sustaining an mtbi are as high as 19.5% In the military, mtbi is more highly associated with PTSD than more severe TBI
Concussion, mtbi, and PCS While concussion is a less stigmatizing term than mtbi, not everyone agrees the terms are synonymous The brain injury may be confused with its functional sequelae, which are labeled as PCS It can be argued that concussion should be considered a chronic disorder that extends beyond the initial injury
Concussion 1.1 million visits to the ED annually Majority produce only transient changes in neurological status that spontaneously resolve Recovery is usually within minutes to hours to days post injury for the majority This talk will focus on the minority mtbi has become the signature injury of the wars in Afghanistan and Iraq
Neuropathology The central factor determining severity of TBI is how transient or permanent the degree of axonal injury Neural damage occurs by traumainduced biomechanical and biochemical changes to the axon and protein scaffold
Neurometabolic Cascade Physiologic alterations induced by cellular deformation followed by restoration of function and return to baseline explains the acute effects of sports concussion The transient nature of this cascade provides a framework for why the majority of mtbi s have a favorable outcome
Neurometabolic Cascade Vagnozzi et al. looked at concussed athletes with a negative MRI, but then underwent MRS at 3, 15, 22, and 30 days post injury NAA (N-acetylaspartate) levels reflected initial pathologic changes that normalized over time Talavage et al. used fmri to assess concussed athletes and demonstrated prolonged activation anomalies beyond the timeframe which cognitive functions normalized These studies show that neuropsych measures often return to baseline before physiologic restoration occurs
Poor Outcome from mtbi The Biopsychosocial Model
Biopsychosocial Perspective This perspective embraces a multifactorial, interwoven, biopsychosocial conceptualization of poor outcome from mtbi Evidence so far concludes that this is a reasonable approach to understanding the problem Applicable to athletes and non-athletes
Biopsychosocial Conceptualization Figure 3.1 PTSD and Mild Traumatic Brain Injury, 2012
PCS Most clinicians and researchers agree there is a sub-group of people reporting symptoms long after a mtbi There is lack of consensus as to what is causing and maintaining the symptoms and problems PCS symptoms Fatigue easily, disordered sleep, HA, dizziness, irritability, anxiety/depression, personality changes, apathy
Conundrum PCS is a nonspecific cluster of symptoms that can be mimicked by other pre-existing conditions Healthy adults report HA, sleep difficulty, irritability, and memory loss commonly in daily life Multiple studies show PCS symptoms are common in clinical groups Outpt psych, personal injury, chronic pain, and whiplash
Anxiety Feelings of anxiety are common in PCS Loss of self-esteem Fear of permanent brain damage May enhance original symptoms resulting in a vicious circle Common to see exacerbation of pre-injury anxiety problems in those with a mtbi Ponsford reported in 2000 that patients with symptoms at 3 months post-injury were likely to experience high levels of stress and anxiety
Anxiety Anxiety disorders seen in PCS may include* Generalized anxiety disorder Panic disorder Obsessive compulsive disorder Specific phobias (driving) PTSD *Warden and Labbate. Textbook of Traumatic Brain injury. 2005. P231-243
Depression Is PCS mainly a depressive disorder? A challenging diagnostic consideration in patients with poor outcome after mtbi Concern that TBI s alter brain physiology and/or create a psychological burden, resulting in a patient developing depression Rates of depression in the first 3 months following a mtbi range from 12-44% across multiple studies over the past ten years.
Depression Bombardier et al. JAMA 2010 reported that MDD after TBIs (all severity) is highly prevalent and associated with increased comorbidity and disability The prevalence of MDD in their study population was 7.9 times higher than would be expected in the general population
Depression Bombardier also found that people who suffer TBI s (all severity) had higher rates of pre-injury psychiatric disorders Depression Substance abuse People with a h/o depression are at greater risk of developing depression after brain injury
Depression Can arise Directly or indirectly from neurobiological sequlae of the brain injury Psychological reaction to deficits and problems associated with the brain injury Comorbid condition with an anxiety disorder (PTSD, chronic pain, insomnia) Combination of the above
Treatment
PCS Interventions Psychoeducation Provision of information Routine early assessment Multidisciplinary follow up Address physical, cognitive, psychological issues Cognitive Behavioral Therapy Medications
Ongoing Symptoms in PCS Between 15-20% of mtbi patients may experience ongoing symptoms Pre-injury psychiatric history is a strong predictor of ongoing PCS mtbi itself also is a strong contributor to these symptoms in the early stages Pain, concurrent anxiety, and other life stressors contribute to symptoms in the longer term
Ongoing PCS Symptoms Tiersky et al. reported in 2005 While psychiatric factors undoubtedly play a role in chronic PCS, it seems most likely that both cognitive and other neurological deficits and emotional distress contribute to continuing PCS after a mtbi Both of these aspects of the disorder need to be addressed in treatment Tiersky et al. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86, 1565-1574
Early Education PCS is associated with high levels of anxiety Anxiety levels are higher in patients who aren t given info on what symptoms to expect and how to cope Education is best delivered at the time on injury (ER, training room) Patient reassurance is an important aspect of early education
Early Intervention A Vietnam era study showed that when patients with mtbi were encouraged to get up early, given physiotherapy, educational info, doctor f/u, and encouraged to resume normal activity, they had fewer days off work than patients getting information only as requested
Early Intervention A 2006 study looked at an mtbi intervention group who received OT and medical appts with a physician and neuropsychiatrist 1 week from injury vs a control group who did not receive follow up There were no significant differences in the groups except in participants with a h/o psychiatric illness. The intervention group did better
Treating Physical Problems Important to address co-morbid physical injuries Referral to relevant medical specialists Scans or xrays where appropriate Physical therapy Pharmacologic treatment for msk pain Treat HA, balance, vertigo, dizziness, hearing and sleep issues as these exacerbate stress levels
Psychological Therapy Individuals with persistent PCS show increased anxiety levels CBT may be used to alleviate anxiety and depression Symptom maintenance and treatment Mastery over symptoms, taking control of lifestyle, thought stopping, encouragement
Sports-Specific Considerations Athletes have strong motivation to RTP They do face unique stressors and this aspect of their mgmt is sometimes neglected In 2002, Johnston et al. showed that participating in a social support group resulted in improved mood, and reduced anger, confusion, frustration, anxiety, depression, and isolation in concussed athletes
Medication Limited evidence supporting any medication use for mtbi Care must be used because treatment of one symptom can exacerbate other deficits One small study showed a positive effect of SSRI, sertraline, for depression and cognitive function in PCS More recent studies have not duplicated this result
Conclusion Anxiety, depression, somatic preoccupation are relatively common after concussion Symptoms of anxiety and depression can mimic PCS Concussion is a multifaceted condition requiring multifaceted treatment Initiated soon after injury Individuals with a h/o psychiatric disorder may be more vulnerable to prolonged symptoms
Thank you! Primary Source: PTSD and Mild Traumatic Brain Injury. 2012. Edited by Vasterling J.J., Bryant R.A., Keane T.M.