Mild Traumatic Brain Injury and Post- Concussion Syndrome: Diagnosis, Treatment and Controversy

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2 Mild Traumatic Brain Injury and Post- Concussion Syndrome: Diagnosis, Treatment and Controversy Joel J. Silverman, MD Virginia Commonwealth University

3 Joel J. Silverman, MD Disclosures Research/Grants: None Speakers Bureau: None Consultant: None Stockholder: None Other Financial Interest: None Advisory Board: None

4 Learning Objective Identify 4 treatment principles for mild traumatic brain injury

5 The Brain Is Our Organ More cells than stars It gets injured Sports (3%) Vehicular accidents (50%) Falls (21%) Violence (20%) War NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury. JAMA 1999;282:

6 Epidemiology Men ages (15-20% combat troops in current wars) Children accidents & abuse million per year in USA 2 75% MTBI 3 TBI most common neurologic disorder after HA/herpes 4 HA = headache; MTBI = mild traumatic brain injury; TBI = traumatic brain injury 1. NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury. JAMA 1999;282: Langlois JA. CDC National Center for Injury Prevention and Control; CDC. Report to Congress on MBTI in the US Kurtzke JF. Ann Neurol 1984;16:

7 Huge Costs Financial Psychosocial Functional Psychiatric Interpersonal Physical

8 Our Role as Psychiatrists Do No Harm Diagnose Treat (early) Forensic evaluations

9 One Definition of MTBI A person who has had a traumatically induced physiological disruption of brain function as manifested by at least one of the following: Any LOC < 20 minutes, but Any amnesia < 24 hours best indicator, but Any alteration in mental state at the time of the accident (i.e., feeling dazed, disoriented, confused) but 24 hours best indicator, but GCS Neurological exam (initial seizures, lesions, aphasias, gait disorders, anosmia) Imaging (MRI, CT) CT = computed tomography; GCS = Glasgow Coma Scale; LOC = loss of consciousness; MRI = magnetic resonance imaging MTBI Committee of Rehabilitation Medicine. J Head Trauma Rehab 1993;8:86-87.

10 Controversy So, it is often really hard to diagnose Diagnosis really matters Diagnosis impacts expectation for doctor and patient Pre-eminent questions: What are clinically useful diagnostic criteria? Who had a physiological disruption of brain function?

11 Differential Diagnosis PTSD Depression Substance abuse Anxiety disorder ADHD Malingering Iatrogenic ADHD = attention deficit hyperactivity disorder; PTSD = post traumatic stress disorder

12 Major Overlaps PCS PTSD MAD Chronic HA Malingering Substance Abuse Fatigue X X X X X X Sleep D/O X X X X X X Headache X? X X X X Dizziness X X? X X X Irritability X X X X X X Anxiety X X X X X X Depression X X X X X X Personality D/O X X X? X X Apathy X X X? X X Concentration X X X X X X Memory X X X? X X D/O = disorder; MAD = major affective disorder; PCS = post-concussion syndrome

13 Mechanisms of Injury Contusions Contrecoup 2 Sudden deceleration Impact not required, but Traumatic Axonal Injury (DAI) Injury proportional to force Controversial No Shearing Controversial Mechanical Stretched neurons Chemical DAI = diffuse axonal injury

14 Neurotransmitter Changes Glutamine Catecholamines Serotonin Acetylcholine Norepinephrine Others

15 Short-Term Effects of MTBI Headache, fatigue, dizziness, photophobia, sleep, hyperacusis Attention Concentration Memory Irritability Depression Anxiety Relationships Work

16 Clinical Evaluation History patient and others Accident Pre-accident and post-accident Standardized questionnaires (GOAT) Neurologic exam Neuroimaging Psychiatric exam Neuropsychological assessment Standardized academic testing and grades GOAT = Galveston Orientation and Amnesia Test

17 G.O.A.T. Levin HS. J Nerv Ment Dis 1979;167:

18 Research Tools SPECT Computerized EEG Auditory evoked potentials Diffusion tensor imaging (DTI) S-100B, a neuroprotein EEG = electroencephalogram; SPECT = single photon emission computed tomography

19 Risk Factors Stress at time of accident Post-accident depression/anxiety Social support Headache and dizziness Alexander M. Neurology 1995;45:

20 Course of MTBI Athletes baseline in 2 21 days MVA recovered in 3 months Worst is first MVA = motor vehicle accident

21 Athletic Injuries NFL 650 players with 887 concussions No one failed to return to play 56% in 1 6 days 36% in 7 14 days 6.5% in more than 14 days No measurable effect on cognitive function after acute recovery NFL = National Football League Iverson GL. Curr Opin Psychiatry 2005;18:

22 Military Injuries TBI a common injury 15 20% MTBI in Iraq and Afghanistan Compared with soldiers with other injuries, MTBI with LOC had more Poor health Missed work Medical visits PPCS symptoms However, after adjusting for depression and PTSD No association between MTBI and physical health outcomes/symptoms except HA PPCS = persistent post-concussion syndrome Hoge CW, et al. N Engl J Med 2008;358:

23 Treatment Principles Do No Harm Realistic reassurance = evidence-based optimism Education Diagnose and treat early Silver JM, et al. Am J Psychiatry 2009;166:

24 Treatment Considerations Evaluate life stressors Pain Psychiatric disorders: Pre-existing and post Occupational intervention: Back on the horse Family involvement CBT Great care with meds that impact and may worsen CNS function Polypharmacology - + s and s Start low go slow Avoid narcotics Side effect sensitivity CBT = cognitive-behavioral therapy; CNS = central nervous system Silver JM, et al. Am J Psychiatry 2009;166:

25 Treatment Options Depression Sertraline Citalopram Concern: bupropion and seizures Cognitive Speed of information Memory Donepezil Silver JM, et al. Am J Psychiatry 2009;166:

26 Persistent Post- Concussion Syndrome

27 What Is Post-Concussion Syndrome? Must have had: A significant cerebral concussion Three other symptoms X 3 months Loss of consciousness Amnesia Seizures Or is it a psychological-psychosomatic extension of a previous brain injury? Or is it expectation plus? Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association

28 Prevalence of PPCS 40% at 3 months % at 6 months 2 < 6% at 1 year 3 1. Keshavan MS, et al. Br J Psychiatry 1981;138: Bohnen N, et al. Neurosurgery 1992;30: Alves WM. PhysiMed Rehab 1992;6:21-32.

29 PPCS Predictive Factors Anxiety Chronic pain Depression Female Headache Litigation Lower SES Prior TBI Serious injury Social problems Substance abuse SES = socioeconomic status Fenton G, et al. Br J Psychiatry 1993;162: Ettlin TM, et al. J Neurol Neurosurg Psychiatry 1992;55: Alexander MD. J Head Trauma Rehab 1992;7:60-69.

30 Test for Malingering Amsterdam Short-Term Memory Test MTBI Litigant 61% MTBI Non-Litigant 29% Schmand B, et al. J Neurol Neurosurg Psychiatry 1998;64:

31 MTBI with Orthopedic Controls Sample > 200 Lithuania Litigation rare 3 Months MBTI (n = 200) Control (n = 210) 12 Months MBTI (n = 192) Control (n = 215) 6 Core PCS Symptoms MTBI Controls 2 (1%) 3 (1.5%) 1 (0.5%) 1 (0.5%) 3 Core PCS Symptoms MTBI Controls 78% 47% Mickeviciene Dl, et al. Eur J Neurol 2004;11:

32 PPCS Following MTBI Rare in prospective studies Seen equally in post-mtbi and non-brain injury trauma Usually no neuropsychological test evidence of organic brain disorder Not predicted by original peritraumatic amnesia

33 Perception/Expectation Impacts 25% of patients with concussion have some symptoms (but not necessarily from a concussion) persist at least a year. It is getting increasingly difficult to find good scientific evidence that MTBIs are associated with demonstrable cognitive deficits where symptoms are due to the biologic effects of the injury in more than a small minority of patients who are more than 3 months postinjury. Iverson GL. Curr Opin Psychiatry 2005;18: Grant Iverson

34 Perception/Expectation Impacts Post-concussion-like symptoms are common in healthy subjects and patients with no history of brain injury, outpatients seen for minor medical problems, in personal injury claimants, patients with PTSD, patients with orthopedic injuries, individuals with prior pain, and patients with whiplash. The effects of MTBI on neuropsychological functioning after the acute recovery period are considerably less than the effects of litigation, depression, or ADHD. Iverson GL. Curr Opin Psychiatry 2005;18: Grant Iverson

35 Expectation People never head-injured reported the usual, expected symptoms of MTBI correctly Early and late experience reinforces expectation Prior symptom levels underestimated Mittenberg W, et al. J Neurol Neurosurg Psychiatry 1992;55:

36 Effect Sizes on Neuropsychological Functioning Iverson GL. Curr Opin Psychiatry 2005;18:

37 Effect Sizes on Memory Functioning Iverson GL. Curr Opin Psychiatry 2005;18:

38 Conclusions Presence of Cognitive Deficits HI = Cognitive Deficits Cognitive Deficits HI Must make sense Severity defined by injury characteristics When they don t, think psychiatry etiology Symptoms improve HI = head injury Stuss DT. Neurology 1995;45:

39 Conclusions MTBIs and PPCSs exist Real MTBIs have short-term impacts on cognition, emotions, neurologic function They are under-diagnosed and they are over-diagnosed Very heterogeneous They are very hard to accurately diagnose Need more than dazed and symptoms Need real traumatic insult to the brain

40 Conclusions (cont.) Most MTBIs heal during first week to 3 months Primary injury does not get worse over months First is worse! Head injury causes the presence of cognitive deficits, but the presence of cognitive deficits does not necessarily mean head injury PPCS: Think expectations Think rehabilitation Think biopsychosocial The field badly needs better diagnostic tools

41 Summary

42 an educational series offered by CME Outfitters, LLC This CME/CE activity is co-sponsored by

43 Mild Traumatic Brain Injury and Post Concussion Syndrome: Diagnosis, Treatment and Controversy Joel J. Silverman, MD Alexander M. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology 1995;45: Alexander MD. Neuropsychiatric correlates of persistent postconcussive syndrome. J Head Traum Rehab 1992;7: Alves WM. Natural history of post-concussive signs and symptoms. Phys Med Rehab State Art Rev 1992;6: Bohnen N, Jolles J, Twijnstra A. Neuropsychological deficits in patients with persistent symptoms six months after mild head injury. Neurosurgery 1992;30: ; discussion Centers for Disease Control and Prevention. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta, GA: Department of Health and Human Services (US), CDC, National Center for Injury Prevention and Control; Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. (DSM-IV-TR). Washington, DC: American Psychiatric Association; Ettlin TM, Kischka U, Reichmann S, et al. Cerebral symptoms after whiplash injury of the neck: a prospective clinical and neuropsychological study of whiplash injury. J Neurol Neurosurg Psychiatry 1992;55: Fenton G, McClelland R, Montgomery A, MacFlynn G, Rutherford W. The postconcussional syndrome: social antecedents and psychological sequelae. Br J Psychiatry 1993;162: Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. Soldiers returning from Irag. N Engl J Med 2008;358: Iverson GL. Outcome from mild traumatic brain injury. Curr Opin Psychiatry 2005;18: Keshavan MS, Channabasavanna SM, Reddy GN. Post-traumatic psychiatric disturbances: patterns and predictors of outcome. Br J Psychiatry 1981;138: Kurtzke JF. Neuroepidemiology. Ann Neurol 1984;16: Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, Nation Center for Injury Prevention and Control; Levin HS. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J Nerv Ment Dis 1979;167: Mickeviciene D, Schrader H, Obelieniene D, et al. A controlled prospective inception cohort study on the post-concussion syndrome outside the medicolegal context. Eur J Neurol 2004;11: Mittenberg W, DiGiulio DV, Perrin S, Bass AE. Symptoms following minor head injury expectation as etiology. J Neurol Neurosurg Psychiatry 1992;55: MTBI Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. Definition of mild traumatic brain injury. J Head Trauma Rehab 1993;8: NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury. Rehabilitation of persons with traumatic brain injury. JAMA 1999;282: Schmand B, Lindeboom J, Schagen S, Heijt R, Koene T, Hamburger HL. Cognitive complaints in patients after whiplash injury: the impact of malingering. J Neurol Neurosurg Psychiatry 1998;64: Silver JM, McAllister TW, Arciniegas DB. Depression and cognitive complaints following mild traumatic brain injury. Am J Psychiatry 2009;166: Stuss DT. A sensible approach to mild traumatic brain injury. Neurology 1995;45: