General Disclaimer (learned from Dr. Melhorn)

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1 Mild Traumatic Brain Injury: Postconcussion Syndrome, Persistent Posttraumatic Headache, etc. Robert J. Barth, Ph.D. Chattanooga, TN and Birmingham, AL General Disclaimer (learned from Dr. Melhorn) All contents of this presentation remain the property of Dr. Barth, and cannot be used for any purpose in the absence of Dr. Barth s specific authorization. Mild Traumatic Brain Injury (MTBI) Question and Answer format 1

2 MTBI Questions Is permanent cognitive impairment associated with MTBI? Is postconcussion syndrome caused by MTBI concussion? Does head trauma cause prolonged headaches? >>> MTBI Questions What are the typical causes of a claim of prolonged postconcussion syndrome? Are these people faking? What does neuropsychological testing have to offer for such cases? What can we do for someone with prolonged complaints? MTBI Bottom Line: 2

3 MTBI Bottom Line: MTBI Bottom Line: Not associated with permanent impairment. PCS is not correlated with MTBI- concussion. Head trauma is not correlated with prolonged headache. >>> Non-injury-related related factors are the best predictors of prolonged complaints following MTBI. Our job in the assessment of such cases is to identify relevant non-injury- related issues for the individual examinee, and to create a treatment plan based on those findings. MTBI Question #1 Is permanent cognitive impairment i associated with MTBI? 3

4 1. Is permanent cognitive impairment associated with MTBI? Answer: NO Permanent cognitive impairment is NOT associated with MTBI. Examples of relevant literature Examples of relevant literature The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury Carroll LJ, Cassidy JD. PROGNOSIS FOR MILD TRAUMATIC BRAIN INJURY: RESULTS OF THE WHO COLLABORATING CENTRE TASK FORCE ON MILD TRAUMATIC BRAIN INJURY. J Rehabil Med 2004; Suppl. 43:

5 The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury reviewed 428 studies "The stronger studies, utilizing appropriate control groups and controlling for confounding factors, suggest that post-concussion symptoms are largely resolved within three months to a year. Would you believe a week? >>> The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury reviewed 428 studies Studies that examined the relationship between litigation and/or compensation issues and slower recovery after mild traumatic brain injury consistently reported an association between them. Examples of relevant literature Meta-Analysis of neuropsychological test data: Binder, L. M., Rohling, M. L., and Larrabee, G. J. (1997). A Review of Mild Head Trauma, Part I. Journal of Clinical and Experimental Neuropsychology, 19, pp

6 Meta-Analysis of neuropsychological test data: Test effects from MTBI average the equivalent of two (2) IQ-equivalent points on intellectual or memory testing. This effect size is SMALLER THAN the standard error of measurement. You get a bigger effect size by administering the testing twice to a perfectly healthy person. >>> Meta-Analysis of neuropsychological test data: The effect size for MTBI is smaller than the effect sizes associated with Litigation Hypertension MTBI Question #2 Is postconcussion syndrome caused by MTBI concussion? NO 6

7 Postconcussion syndrome is NOT caused by MTBI concussion PCS in the non-brain brain-injured injured general population Iverson GL & Lange RT. Applied Neuropsychology, 2003, 10: How many healthy people without a history of head injury satisfied diagnostic criteria for PCS? DSM-IV Criteria 79.6% How many healthy people without a history of head injury satisfied diagnostic criteria for PCS? ICD-10 Criteria 72.1% 7

8 PCS in the non-brain-injured injured general population Bottom Line: The historical-formal conceptualizations ti of postconcussion syndrome are NOT actually correlated with whether someone has had a concussion Postconcussion syndrome is NOT caused by MTBI concussion PCS in the non-brain-injured injured claimant/plaintiff population Dunn JT et al. J Clin Psychology, 1995, 51: Ingebrigtsen T et al. J Neurology, 1998, 245: PCS in the non-brain brain-injured injured claimant/plaintiff population Non-TBI Claimants Headache 77% MTBI 3 months post 42% 77% 42% Dizziness 41% 26% Irritability 63% 28% Memory sx 46% 36% Concentration sx 71% 25% 8

9 PCS in the non-brain brain-injured injured claimant/plaintiff population Bottom Line: The historical conceptualizations of postconcussion syndrome are more strongly associated with filing a medical-legal legal claim, rather than being specific to a history of concussion. Postconcussion syndrome is not actually correlated with whether someone has had a concussion This is one of many reasons why postconcussional disorder was REJECTED by the American Psychiatric Association, when considered for inclusion in the Association s diagnostic system postconcussional disorder was REJECTED by the American Psychiatric Association Two reasons why I am pointing this out 1. Personal grudge DSM-IV-TR page AMA research project showed postconcussion syndrome to be one of the most commonly claimed mental illnesses in workers comp (when in fact it is not a recognized mental illness). 9

10 MTBI Question #3 Does trauma cause prolonged headaches? NO Trauma is not a cause of prolonged headaches Berry H. Chronic whiplash syndrome as a functional disorder. Arch Neurol Apr;57(4): Study of Demolition Derby Drivers Average collision experience per driver: 1900 collisions/driver How many have clinically significant headache problems: 0 Trauma is not a cause of prolonged headaches Couch JR, Bearss C. Chronic daily headache in the posttrauma syndrome: relation to extent of head injury. Headache Jun;41(6): the risk of developing posttraumatic chronic daily headache is greater for less severe head injury 10

11 Trauma is not a cause of prolonged headaches In other words: In terms of both incidence and severity, trauma is NOT correlated with headache. h All of this is the exact opposite of a causative connection between trauma and the headaches, according to health causation standards Trauma is not a cause of prolonged headaches Obelieniene D, et al. J Neurol Neurosurg Psychiatry Mar;66(3): Headache is common immediately following head trauma, but such headache is associated with an overwhelmingly positive prognosis (maximum duration outside of a compensation context = 20 days). Outside of a legal claims context, the percentage of trauma patients who continue to complain of headache is essentially the same as the percentage of non-injured people who complain of persistent headaches. Trauma is not a cause of prolonged headaches Schrader H, et al. Lancet May 4;347(9010): the vast majority (85%) of people who complain of frequent headaches following a trauma, but who are removed from litigation/compensation contingencies, acknowledge that they also had frequent headaches prior to the trauma. 11

12 Trauma is not a cause of prolonged headaches Warner, J. S. and Fenichel, GM (1996). Chronic posttraumatic headache often a myth? Neurology, 46, pp In research focused on claims of persistent posttraumatic headache, more than 80% of the sample of such patients were found to actually have a non-injury injury-related related headache syndrome. In most cases, the true diagnosis was medication- induced headache. For those cases, a treatment plan focused on medication elimination led to the headache going away. Trauma is not a cause of prolonged headaches Such scientific findings are supportive of textbook conclusions that medication (e.g. narcotics, ergotamine derivatives, nsaids, etc.) is the necessary and sufficient cause of chronic daily headache complaints. Levenson JL. Textbook of Psychosomatic Medicine. American Psychiatric Publishing; Trauma is not a cause of prolonged headaches Mathew NT. Chronic refractory headache. Neurology Jun;43(6 Suppl 3):S patients with chronic daily headache 73% overused symptomatic medication, particularly analgesics and ergotamine, and as a result, suffered from drug-induced headache or rebound headache. The medication over-utilizers also commonly reported: Fatigue Irritability Depression Memory difficulties Headache worsening with small amounts of effort (mental or physical) 12

13 Trauma is not a cause of prolonged headaches Mathew NT. Chronic refractory headache. Neurology Jun;43(6 Suppl 3):S The medication over-utilizers also commonly reported: Chronic headache Fatigue Irritability Depression Memory difficulties Headache worsening with small amounts of effort (mental or physical) Is it just me??? Or does this medication over-utilization syndrome appear to be awfully similar to the failed concepts of PCS? Trauma is not a cause of prolonged headaches In the absence of a claims context and medications, the most common cause of persistent headaches is various forms of depression or anxiety. Ropper AH, and Brown, RH (2005). Adams and Victor's Principles of Neurology, Eighth Edition. McGraw-Hill. Question #4: What are the typical causes of a claim of prolonged postconcussion syndrome? 13

14 What are the typical causes of a claim of prolonged postconcussion syndrome? The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury Carroll LJ, Cassidy JD. PROGNOSIS FOR MILD TRAUMATIC BRAIN INJURY: RESULTS OF THE WHO COLLABORATING CENTRE TASK FORCE ON MILD TRAUMATIC BRAIN INJURY. J Rehabil Med 2004; Suppl. 43: (continued) The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury "The most consistent predictors of delayed recovery after mild traumatic brain injury are compensation and litigation factors, independent of mild traumatic brain injury severity." The World Health Organization s Collaborating Center Task Force on Mild Traumatic Brain Injury the question of whether pre-morbid personality is an important predictor of persistent symptoms after mild traumatic brain injury. One study that addresses this issue in a unique and highly selected sample of individuals who had been administered psychological tests prior to their injury found that post-mild traumatic brain injury psychological problems reflected pre-morbid personality, rather than the effects of the injury." 14

15 What are the typical causes of a claim of prolonged postconcussion syndrome? Iverson GL. Outcome from mild traumatic brain injury. Current Opinion In Psychiatry, 2005, May, 18 (3), All of the following have a stronger effect than does MTBI All of the following have a stronger effect than does MTBI Claims context Mood disorders ADHD Exaggeration/malingering Benzodiazepines Marijuana Symptomatic HIV >>> What are the typical causes of a claim of prolonged postconcussion syndrome? Remember that we already saw that hypertension has a stronger effect than does MTBI. We have only talked about the issues that t have been shown, in head to head comparison, to have a stronger effect than MTBI. Note that there are many other neuropsychological risk factors that we have not yet talked about, which also need to be considered. 15

16 What are the typical causes of a claim of prolonged postconcussion syndrome? Mittenberg W., et al. (1992). Symptoms Following Mild Head Injury: Expectation As Etiology. Journal of Neurology, Neurosurgery, and Psychiatry, 55, pp PCS is dependent upon the extent to which the postconcussive individual id attributes t non-injury injury- related shortcomings to the injury (example, they overlook any history of pre-existing existing headache, and attribute all current headaches to the MTBI). catastrophizing, avoidance, maladaptive coping, creating distress, stress, and disability. Question #5 Are these people faking? Are these people faking? These data show base rates of malingering g that approach or exceed 50%... Larrabee GJ. Assessment fo Malingered Neuropsychological Deficits. Oxford,

17 Question #6 What does neuropsychological consultation have to offer for such cases? Neuropsychological consultation does NOT offer Assessment of impairment from MTBI Because there is no credible basis for claiming that such impairment exists Neuropsychological consultation DOES offer Objective assessment of whether there is any type of cognitive impairment (there might not be) 17

18 Neuropsychological consultation offers If there is significant impairment, the consultation might provide diagnostic clues (we know that the MTBI is not the cause of the impairment, so a neuropsychology consultation might help us develop alternative diagnostic hypotheses) Neuropsychological consultation offers Objective assessment of whether the examinee s presentation is consistent with faking. Neuropsychological consultation offers objective assessment of whether the examinee s presentation is consistent with faking Psychology has extensively researched the phenomenon of malingering 18

19 Psychology has extensively researched the phenomenon of malingering Many tests have been scientifically validated for the objective assessment of malingering for -cognitive complaints -mental illness -pain complaints Psychology has extensively researched the phenomenon of malingering Warning!!! Researchers are scared of being sued, therefore Almost all of the research is designed to miss many to most examinees who are faking This helps to insure that when a malingering-like like result is obtained, we are indeed probably dealing with someone who is faking But when a honest-like result is obtained, we cannot claim with probability that the examinee has been honest with us. Question #7 What can we do for someone with prolonged postconcussive complaints? 19

20 Credible treatment for claims of prolonged PCS Cognitive behavior psychotherapy focused on: Teaching the patient to re-evaluate evaluate symptoms as possibly normal shortcomings Teaching patient to avoid over-reacting reacting to such perceived symptoms Teaching the patient to avoid becoming stressed by such perceived symptoms NOTE: This psychotherapy approach is the ONLY scientifically validated specific treatment for PCS. Mittenberg W, et al. Cognitive-behavioral prevention of postconcussion syndrome. Archives of Clinical Neuropsychology, 1996, 11, Treatment Issues of direct relevance to claims of prolonged posttraumatic headache Credible treatment for claims of prolonged posttraumatic headache Medication Detox Cognitive behavior psychotherapy focused on maintaining a normal life in spite of the pain. Levenson JL. Textbook of Psychosomatic Medicine. American Psychiatric Publishing;

21 Treatment Critically important, and reliably beneficial issues of general relevance to claims of all types A credible treatment plan will have a front and center focus on 1. Helping the patient to get out of the claims system as quickly as possible. -Involvement in claims systems is reliably bad for the patient s health Binder, L. M. and Rohling, ML (1996). Money matters: A meta- analytic review of the effects of financial incentives on recovery after closed head injury. American Journal of Psychiatry, 153,7-10. A credible treatment plan will have a front and center focus on 2. Keeping the patient working g( (or returning the patient to work) Barth, RJ, and Roth, VS. (2003). Health Benefits of Returning to Work. Occupational and Environmental Medicine Report, 17, 3, March, 2003, p

22 A credible treatment plan will have a front and center focus on 3. Avoiding excessive treatment ACOEM Guidelines: Over-treatment is a greater risk to the patient s health than under- treatment would be. A credible treatment plan will have a front and center focus on 4. Minimizing/eliminating dependence on disability benefits (a critical part of the treatment plan) - Disability benefits reliably lead to a worse clinical outcome Binder, L. M. and Rohling, ML (1996). Money matters: A meta- analytic review of the effects of financial incentives on recovery after closed head injury. American Journal of Psychiatry, 153,7-10. A credible treatment plan will have a front and center focus on 5. For any claim that involves disability or chronicity without crystal clear, inarguable, scientifically credible justification Assume that mental illness or some other form of psychological factors are playing a role Investigate for it When identified, offer a treatment plan focused on those psychological factors. Barth, RJ. Undiagnosed Mental Illness as the Cause of General Medical Disability Claims. The Guides Newsletter. November/December, American Medical Association. 22

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