psychiatric*treatmentof*the* concussed*athlete* · 2018. 4. 1. · concussions may be more severe...
TRANSCRIPT
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Psychiatric Treatment of the Concussed Athlete
American Osteopathic Academy of Sports Medicine 2015 Annual Conference
Alexander S. Strauss, MD Centra, P.C. Marlton, NJ
Clinical Assistant Professor, Rutgers RWJ
E-‐MAIL: [email protected]
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Disclosures of Poten7al Conflicts Source Research
Funding Advisor/
Consultant Employee Speaker
Bureau Books,
Intellect. Property
In-kind Services
(example: travel)
Stock or Equity > $10,000
Honorarium or expenses
for this presentation or meeting
None
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Today • My interest
• Importance
• Epidemiology
• Defini7ons • Evalua7on • Neuropsychiatric complica7ons
• Treatment
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My Interest Spring Training 2005
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Concussions May Be More Severe in Girls and Young Athletes ... – May 10th, 2012
Evidence Mounts Linking Head Hits To Permanent Brain Injury -December 03, 2012
Concussions may cause lingering mental anguish – May 14th, 2014
Did multiple concussions lead to OSU football player’s suicide? – 12/1/2014
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Post Concussive Symptoms
• CogniOve Symptoms • “Fogginess” • Difficulty concentra7ng • Memory deficits • Cogni7ve Fa7gue
• Sleep AlteraOons • Difficulty falling asleep • Fragmented sleep • Too much/too liJle sleep
• SomaOc Symptoms
• Headaches (up to 78%) • Dizziness (up to 50%) • Visual changes • Light/Sound Sensi7vity
• Mood DisrupOon • Irritability • Feeling sad • Anxiety
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Defined by the World Health Organization. ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnositic Guidelines. 1992.
Defined by the Diagnositic and Statistical Manual of Mental Disorders (DSM-5) – Major or mild neurocognitive disorder due to traumatic brain injury.
Post Concussive Syndrome
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Postconcussive Syndrome-‐ ICD-‐10 • A. History of head trauma… preceding symptom onset by a maximum of 4 weeks.
• B. Symptoms in 3 or more of the following symptom categories: – Headache, dizziness, malaise, faOgue, noise intolerance;
– Irritability, depression, anxiety, emoOonal lability; – SubjecOve concentraOon, memory or intellectual difficulOes
without neuropsychological evidence of marked impairment;
– Insomnia; – Reduced alcohol tolerance; – May be accompanied by a preoccupaOon with above symptoms,
fear of brain damage with hypochondriacal concern and adopOon of sick role
ICD-10 .
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Neuropsychiatric Complica7ons • Cogni7ve Deficits (25-‐70%) • Depression (25-‐50%) • Anxiety (10-‐77%) • Sleep problems (30-‐70%) • Agita7on & Aggression (~30%) • Suicide (~3x Incidence) • Substance use disorders
• Psychosis
• Obsessive compulsive disorder
• Personality changes • Alzheimer’s disease
• ADHD • Mania (1-‐10%)
• Stress Disorders • Apathy (10%)
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– Mild TBI at 12 months follow up 22% developed a psychiatric disorder that they had never experienced before
– With no past psychiatric history the adjusted rela7ve risk is increased compared to no TBI
• Mild TBI ARR = 2.8 (adults)
• Mild TBI ARR = 2.03 (children)
– Past psychiatric history is a significant predictor of psychiatric illness
Fann, JR et al., 2004,Brant, RA et al., 2010, Vaishnavi et al., 2009 and Jorge, RE. 2005, Massagli, TL et al., 2004
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Depression
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Suicide
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Clinical Prac7ce
1. Prior mental illness-‐ exacerba7on ADHD, Anxiety, Depression, PTSD
2. Immediate psychiatric symptoms Anxiety, ADHD, Depression
3. Prolonged recovery – adjustment Depression, Anxiety
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Risk Factors for Protracted Recovery
• Pre-‐exis7ng learning disability • ADHD • Psychiatric illness • Younger age • Prior concussive injury • Amnesia • Chronic headaches or migranes • Over-‐exerters
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Reasons for Referral to Psych
• Exacerba7on of prior mental illness • Complaints associated with mental illness
– Post concussion symptom scale a score 2 to 3 or above (range 0-‐6) in the following categories • Irritability • Sadness • Nervousness • More emo7onal
• Fa7gue or sleep problems • Difficulty with concentra7ng or remembering
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Less Clear Signs and Symptoms
– Symptoms don’t match exam • Over or under repor7ng of symptoms
– Changes in personality • Some become more impulsive others more reserved
– Low mo7va7on • In recovery, in school or outside of school
– Failures in effort – Drop in grades – Hopelessness – Avoidance – Isola7on – Crying
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Treatment
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Educa7on, Support & Guidance – Over 10 studies have been completed
– Mixed results with regard to improvement in symptoms and func7oning
– Overall support and educa7on appear to benefit pa7ents – Reassurance and educa7on may be helpful shortly aner
injury
– Group educa7on and support interven7on and group CBT decreased postconcussive symptoms compared to wait list
Comper DP. et al., 2005 and Snell DL et al., 2009
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Accommoda7ons
• Shortened day • Adjusted class schedule • Breaks • Sea7ng changes • Extra 7me • School counseling
• Progress reports • Quiet areas • Excused ac7vi7es • Academic support • Etc…
Academic- 504 plan in school can include:
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Sleep hygiene and other techniques
• Only go to bed when 7red • Don’t lie in bed more than 20 minutes • Relax each night before bed • Wake up at the same 7me every morning
• Avoid taking naps • Avoid any caffeine aner lunch • Etc…
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Relaxa7on
• Deep breathing • Progressive muscle relaxa7on
• Calming visualiza7on
• Medita7on
• Etc.
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Therapy CogniOve Behavioral Therapy
• Tiersky, LA. et al., 2005 – 20 people with mild to moderate TBI – CBT + Cogni7ve remedia7on 3x per week x 11 weeks v. wait list controls
– Treatment improved emo7onal func7on, lessened anxiety & depression
• Trautmann, et al., 2010 and Powers, et al.,2013 – Studies looked at chronic headaches – Cogni7ve behavioral therapy led to improvement in headache
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Cogni7ve Behavioral Therapy
http://www.ninjasdontsweat.com/blog/2014/4/23/triangles
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Family and Family Therapy
• “Group differences in soma7c symptoms as reported by parents were more pronounced among children from families that were higher func7oning and had more environmental resources.” (Yeates, K. et al., 2012)
• “Mild TBI are associated with family burden and distress more than mild injuries not involving the head, although PCS may influence post injury family burden and distress more than the injury per se.” (Ganesalingam, K. et al., 2008)
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Medica7ons
• No medica7on has FDA approval for the treatment of neuropsychiatric consequences of TBI
• Limited quality research mostly on adults
• Many different medica7ons have been used
Arciniegas DB, et al., 2008
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Cogni7ve Deficits
• Methylphenidate (Ritalin/Concerta) increases aJen7on and processing speed, possibly mood as well
– First line for aJen7on difficul7es – Side effect: headache, loss of appe7te, sleep problems
• Amantadine (Symmetrel) improving cogni7on – Side effects: headache, depression, anxiety, dizzy
• Donepezil (Aricept) increases aJen7on and memory – First line for memory problems in adults
– Side effects: headache, insomnia, nausea
Vaishnavi, et al, 2009, Lombardi, F. 2008, Leone, H. et al., 2005, Lee, et al., 2005 and Gualtieri et al., 1998
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Depression
• SSRIs –Sertraline (Zolob), FluoxeOne (Prozac), Escitalopram (Lexapro) – Side effects: nausea, headache, insomnia, suicidal thinking
• SNRIs – Venlafaxine (Effexor), DuloxeOne (Cymbalta) – Limited data at this 7me
• Bupropion (Wellbutrin) – Cau7on due to increased seizure risk
• Tricyclic anOdepressants (TCAs) – Amitriptyline (Elavil), Nortriptyline – O"en used for headaches in low does. Generally for depression should be avoided in those with cogni:ve dysfunc:on due to an:cholinergic effects
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Disordered Sleep • Melatonin – 3-‐9mg (Over the counter)
– Helps with ini7a7ng sleep • Trazodone
– Helps with ini7a7ng sleep and maintaining sleep – Side effects: Dizzy, headaches, priapism
• Mirtazapine (Remeron) 7.5mg
– Helps with depression and sleep – Side effects: weight gain, dry mouth, seda7on
• Prazosin – Helps with post-‐trauma7c nightmares
• Avoid an7cholinergic meds (Benadryl, ZzzQuil, etc…) as well as benzodiazepines
Vaishnavi et al., 2009
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Case Example
– 15 year old male freshman in high school
– History of concussion and cleared for return to play – “Re-‐injury” with bumpy car ride
– Fear of another re-‐injury – Significant struggles at school and at home
– Parents divorced – Parent with substance use – Not engaging with friends or playing basketball
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Case Example
– 14 year old female 8th grader
– Soccer goalie with head injury of head vs. post – Client with intense desire to return to sport – Headaches won’t resolve despite mul7ple treatments
– Not par7cipa7ng in eye exercises at home
– Frustrated with lack of recovery – No aJending school – Not seeing friends
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Case Example
– 18 year old senior in high school, skiing accident – Aner period of rest “unable” to return to school – Prescribed physical therapy did some
– Prescribed medica7on took one pill, not as prescribed
– Con7nued head pain aner exer7on and fa7gue – Engaged in minimal therapy
– Went off to college and refused an accommoda7on or treatment plan
– Called in crisis a month into school
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Case Example
– 19 year old college sophomore, rugby injury
– Struggles with boyfriend – Partying on most nights
– Failing out of school – Success at community college
– Returned to college only to fail out again – Suicidal leading to par7al hospitaliza7on – Conflict with parents – Neuropsych tes7ng – Treatment for cogni7ve concerns
– Job and school success