Transcription:

Melanie Cole (Host):  Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're exploring concussion from a neuropsychology perspective. Joining me is Dr. Catherine York. She's a Neuropsychologist with the Carle Foundation Hospital. Dr. York, it's a pleasure to have you join us today. It's such an interesting field that you're in and an interesting perspective. We typically hear about concussion from coaches and trainers and sports medicine perspective. But this is going to be just a little bit different. So, tell us a little bit about how and when concussion is diagnosed, bring it around to your perspective for us.

Catherine York, PhD (Guest): So, a concussion is defined as any alteration in brain function caused by an external force. And the way that neuropsychology defines a concussion would be to assess first the loss of consciousness. It would have to be for less than 30 minutes. And second for post-traumatic confusion, which has to be less than 24 hours or a day. So, when we're doing our neuropsychological evaluations, we always make sure to ask the patient not only how did you hit your head and what were the mechanisms behind it, but we ask them if they lost consciousness. And if so, what is the last thing that they remember? What is the first thing that they remember and when did their memories become continuous after that point?

So, when were they able to form new memories again. And again, the loss of consciousness has to be less than 30 minutes and the post-traumatic confusion has to be less than one day for it to meet criteria as a concussion. So, that's the difference between us and maybe sports medicine, where they can be more on the field. But that's part of our clinical interview.

Host: Well, then tell us a little bit about the natural trajectory of the cognitive and psychological symptoms of concussion and the factors that would influence recovery because effective management of the injury can shorten recovery time. We've learned that, but the psychological symptoms, not only from the neuropsych perspective, but from the sports psychology perspective, all of these can encompass concussions even more than one. So, tell us a little bit about how these factors influence recovery and outcomes.

Dr. York: Sure. So, the natural trajectory of the cognitive symptoms of concussions are that they are worse at the time and get better over time. And we would expect that after three months, 93% of the symptoms of the concussion should be resolved with the remaining not having any clear neurological basis. So, immediately after the injury, about five days post-injury, you can see significant cognitive impairments at that time that interrupt daily functioning, but in that subacute period, about five to 30 days post concussions, the cognitive impairments have a gradual overlapping course of improvement with most people achieving full symptom recovery within 30 days, post-injury. After 30 days post-injury we start to become concerned about a chronic period. And it's a very small percentage of patients who report persisting symptoms or other cognitive complaints.

The cognitive symptoms that we usually see and are able to objectively identify through a neuropsychological assessment, primarily pertain to attention and processing speed. So, we'll see reduced working memory, difficulties with sustained and selective attention and slowed processing speed. And again, we would expect that to get better over time. And the NCAA concussion study actually showed that the vast majority of athletes improved in 10 days. And when the researchers adapted that model to a civilian population, the vast majority were recovered within three months. However, like I said, there is that small subset of people who continue to report symptoms greater than 30 days, greater than three months post-concussion and the things that usually interfere with that are any pre-existing medical or psychological problems, high levels of psychosocial stress at the time of the injury and poor social support dealing with the symptoms of the concussion. So the things that we often assess throughout our neuropsychological assessment, such as those premorbid factors being any pre-existing psychiatric problems like depression or anxiety, as well as ADHD or a learning disability.

The physical problems that can come as well as having a concussion, any physical injuries sustained. So, residual post-concussive headaches, insomnia, chronic pain, dizziness, occipital, neuralgia that can happen. And any psychological factors as a result of the concussion, such as depression, anxiety, PTSD, or any pre-existing or afterward substance use disorders. So, really when we're assessing concussions, we're really looking at those post-concussive factors as well as the pre-existing factors that can really slow down that trajectory.

Host: So interesting. And one of the things as we talk to all these different clinicians about return to play and treatment protocols, Dr. York; is this new revision against complete removal of the electronic devices? Are we still saying that these can mess with brain activity, post-concussion? Are we worried about post-concussion syndrome during these times? Tell us a little bit about recovery and treatment and what is new and the latest information.

Dr. York: As far as recovery goes, we really want people to have a period of rest afterwards. But the research is actually showing that cocooning particularly teenagers where we put them into a dark room and have a strict period of rest can actually cause more psychosocial problems afterwards. And that was some research done at the Medical College of Wisconsin that showed that cocooning afterwards, again, that dark room with a strict period of rest can actually lead adolescents to become more anxious and depressed over time and hinder recovery. There was no difference between the group that was cocooned and those that gradually returned to their activities in regards to cognition or physical problems.

So, the goal is really to give people a period of rest, but to get them back to their normal life in a very gradual manner. We don't want them pushing themselves because that could also interfere with your ability to recover and slow things down as well. But as far as screens go, it very much depends on how many posts concussive headaches they're having and dizziness. And I know that's getting in the way right now, especially with schooling being so remote. Some patients, the younger patients that I'm seeing, they're spending a lot of time. They have to be on the computer afterwards. And so I am recommending that they limit that, but we do want people to return to a gradual progression of their activities as soon as possible to get back to normal.

Host: So, interesting as we learn more about this fascinating topic and Dr. York, a big issue that arises in the media and on the field is returned to play. Tell us your thoughts on that as a neuropsychologist, what would you like other clinicians to know about counseling their patients about this? How many is too many and when it's acceptable?

Dr. York: Again, we do gradually want to get people, particularly athletes, back to what they're doing, but we don't want to push them in that and make things worse. One of the biggest things that we need to look for though, is how it does impact their psychosocial functioning. Because a lot of times, being an athlete is part of somebody's identity. So, whether or not they even dress to go to their sports practice or they dress to be part of the team could make a very big difference in their psychosocial outcomes afterwards. So, again, we do really want that gradual return to play, and really focusing on the fact that the longer we keep people from returning to their normal activities, the more it can really influence depression and anxiety afterwards.

And that's something that needs to be closely monitored as well as the physical and the cognitive symptoms post-concussion. So, the number one predictor of how rapidly people get back to normal is actually psychoeducation, which is one of the key components of what a neuropsychological evaluation offers, is during that feedback session, taking time to talk with the patient and the athlete and the student about what type of injury they had. What is the normal trajectory for recovery and assuring them that things are going to get better over time and that they likely do not have brain damage caused by the concussion they had, and then referring them to the appropriate services, like physical therapy, pain management, neurology for headache management. Because if we can let people know in that subacute phase that they don't have brain damage and that things are going to get better over time, things are going to get better over time.

Host: What great information you made, such good points, Dr. York. As we wrap up, what else would referring physicians want to know about concussions from the neuropsych perspective and any new recommendations or advice that you have for recovery, for evaluation and even prevention?

Dr. York: So, the first thing is that from a provider standpoint, it does not hurt to have a neuropsychological evaluation. During that time, we do a lengthy interview with the patient, the athlete, we spend 45 minutes to an hour. We have the luxury of time with them. We're trained clinical psychologists. So, we have the interview to assess all these factors that I'm talking about.

Then we get objective data on attention, memory, executive functioning, to see where the patient's strengths and weaknesses are. And then we again, provide during that feedback session, psycho-education about what's going on. There are a lot of good resources out there right now, as far as showing patients that things are going to get better over time. But I do have to say the earlier that we can get the good news out to them, that things are going to get better with the appropriate treatment, the better they are going to get, and the quicker that they're going to get better.

Host: Great information and such a unique perspective that you have. We're not used to hearing it from that side. And thank you so much. Absolutely fascinating Dr. York. Thank you for joining us. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information, and to get connected with one of our providers.

Please remember to subscribe, rate and review this podcast and all the other Carle Foundation Hospital podcasts. I'm Melanie Cole.