What additional factors should be
considered when symptoms persist?
Elizabeth M. Pieroth, PsyD, ABPP
Board Certified Neuropsychologist
Associate Director, Sports Concussion Program
Disclosures:
Dr. Pieroth has no disclosures to
report.
1.Sleep disturbance
2.Inactivity, particularly in an athlete
3.Affective disorders
4.Malingering/Factitious Disorder
5.Persistent physical injuries
6.Pain
7.Substance use/abuse
8.Somatoform disorders
9.Family dynamics
10.Misinterpretation of cognitive data
11.And …..
Sleep
“Although the exact mechanisms through which TBI affects sleep
and circadian health are not yet fully understood, it is clear that
sleep disturbances and resultant sleep disorders can impair the
brain recovery process.”
“Consequences can include further neurodegeneration, as well as
exacerbation of the many sequelae and comorbidities of mTBI,
including fatigue, hypersomnolence, depressed mood, anxiety,
post-traumatic stress symptoms or PTSD, chronic pain, cognitive
and functional impairments, and diminished health-related quality
of life.”
(Wickwire et al, 2016)
Sleep
• Sleep impacts baseline cognitive testing
(McClure, et al, 2014)
• Preinjury sleep difficulty may exacerbate cognitive
symptoms post-injury
(Sufrinko et al, 2015)
We need to be discussing sleep hygiene issues.
1. Adequate amount of sleep but no more naps!
2. Consistency of sleep/sleep routines
3. No reading/watching TV/computer use in bed
4. Break after last cognitive activity
5. Temperature and light exposure
6. Caffeine intake and food choices
7. Removing electronics from bedroom
8. Use of melatonin/OTC sleep aids
9. Get out of bed after 45 minutes awake
10. Introducing light exercise
Inactivity
How does deconditioning impact cognition, sleep and mood,
particularly in an athlete?
There is increasing evidence that exercise is important in
recovery.
Exercises is associated with neurotransmitter changes which
contribute to improved mood. Exercise may be associated with
improved cognition and school performance in children.
(Silverberg & Iverson, 2015; Leddy et al, 2007; Tan et al, 2014;
Griesbach, 2011)
Affective disorders
Anxiety is a significant problem after TBI (Mallya et al, 2015) but how are we
making it worse?
Strongest predictor for persistent PCS symptoms three months post-injury was
pre-injury physical or psychiatric condition, not TBI (trauma controls)
(Ponsford et al, 2012)
“In contrast to the neurological measures, the presence of self-reported
depressive symptoms following mTBI was significantly associated with
postconcussive symptoms and functional impairment across visits.”
(Dikman et al, 2010)
Measures of resiliency (Losio et al, 2014)
Malingering/Factitious Disorder
Malingering is well-known issue that is frequently
assessed in adult populations.
Even in pediatric samples, evidence of feigning or
exaggeration of cognitive symptoms after concussion is
not uncommon.
(Kirkwood et al 2012; Kirkwood, et al 2014)
Are individual clinicians doing enough to assess poor
effort?
Persistent physical injuries
•Cervical injuries
(Marshall et al, 2015)
•Vestibular dysfunction
(Schneider et al, 2014)
•Oculomotor dysfunction
(Murray et al, 2014)
PainHow does it impact cognitive symptoms?
Somatoform Disorders
Is allowing kids to spend time at home with “complete cognitive
rest” setting them up for increase somatic focus?
Family Dynamics
Are there are issues currently going on at home or in the patient’s
past that are preventing recovery?
Substance use/abuse
Are we adequately assessing substance use in our patients?
Misinterpretation of cognitive test results
• False positives and false negatives
• Overreliance on composite scores
• Not understanding what the subtests are actually
assessing
• Not understanding statistical properties of the test
• Not appreciating the impact of other factors on
cognitive test scores
• Poor testing environment/poor supervision of testing
• Issues with computerized measures
(Bauer et al, 2012; Feenstra et al, 2017)
Let’s not forget the value of an evaluation by a properly
trained healthcare provider….
Evaluation by a specialist within one week of
concussion associated with shorter return-to-play
(Bock et al, 2015)
Thank you!