Cognitive-linguistic correlates in
Athletes and Soldiers
Bess Sirmon Fjordbak, PhD, CCC-SLP
Anthony P. Salvatore, PhD, CCC-SLP, BC-ANCDS
Edina R. Bene, PhD
University of Texas at El Paso
1
Neurometabolic and physical
changes that occur in the brain
secondary to a jarring movement
or external blow
to the body or head.
2
• Deficits observed after a concussion can involve
cognitive-linguistic changes such as:
 impaired concentration
 decreased processing speed
 anomia
 global deficiencies in executive function.
3
• For athletes, the injury can be sustained from a
direct hit, or a jarring motion when hitting the
ground or court surface.
• Among active-duty Soldiers, the injury may also
occur from a pressure wave from close-range
explosive blasts.
4
• Lew et al (2007) called for a team approach
across the federal agencies to care for Soldiers
with TBI given the “coexistence of medical and
psychological issues” in this population.
5
• McCrea et al. (2003) describe post-concussion
deficits in cognitive processing and verbal
memory among collegiate athletes, and
Kennedy et al. (2007) describe similar patterns
among Soldiers.
6
• exposure to a traumatizing event
• subsequent re-experiencing of the event with:
– disruptions in sleep patterns
– changes in arousal
– alterations in cognitive processing
(Kennedy, et al, 2007)
7
• Although recognized as prevalent, variability
in rates of PTSD among returning Soldiers is
reported as ranging from <2% to >30% of that
population. (Sundin et al., 2010)
8
• References to PTSD among post-concussed
athletes were not located in a search of the
literature.
9
• We know that in MVA patients there is a positive
correlation of post-concussion symptoms and
PTSD symptoms. (Bryant et al., 1999)
What is the relationship between post-concussion
symptoms and PTSD symptoms in Soldiers and
Athletes?
10
Similarities between Concussion and PTSD
• cognitive and neuro-vegetative complications
– decreased attention and concentration
– decreased accuracy in memory function
– impaired learning
– slowed processing speed
– headache
– sleep disturbances
– increased irritability
(cf., Chan, 2001; Kennedy, et al., 2007).
11
Similarities between Concussion and PTSD
Schneiderman et al. (2008) surveyed over 2200
post-deployment veterans, and reported that
the most commonly occurring symptoms in
both concussion and PTSD were
sleep disruptions and
increased irritability.
12
Similarities between Concussion and PTSD
On the other hand…
• Hoge, Goldberg and Castro (2009) suggested that
the post-concussive sequelae may be related to
other factors, including acute stress, sleep
deprivation, or other injuries, and indicated that the
symptoms attributed to post-concussive deficits
may be more closely related to PTSD or depression.
13
What is the relationship between
concussion and reported symptoms of
PTSD between athletes and Soldiers?
14
15
Methodology: Population
• Soldiers
– collaborative study with the research team at the
William Beaumont Army Medical Center, assessing
cognitive function in post-deployment Soldiers
experiencing chronic headache.
– 16 Soldiers sustained concussive injuries as a result
of IED blast during active duty assignments, and
were seen for data collection ≥12 months postinjury.
16
PTSD Questions
1. Are you having nightmares?
2. Are you having flashbacks?
3. Are you having trouble keeping thoughts of the incident
out of your head?
4. Are you feeling numb or detached?
5. Are you avoiding similar situations?
6. Are you having difficulty sleeping?
Pts were asked to respond yes or no to each of these questions.
A yes response equals a score of 1 for the specific question.
www.impacttest.com
17
Results: Performance on PTSD Questions
• Soldiers (n = 16)
Time Post Onset
≥
1 yr
Mean score
=
3.75
SD
=
2.05
18
19
Methodology: Populations
• Soldiers
– 7 from the previous cohort
• Athletes
– From a larger sample of collegiate athletes seen at
the Concussion Management Clinic at the University
of Texas at El Paso, 9 were selected from a larger
sample, matched as closely as possible to the
sample of Soldiers.
– The data used for comparison in this investigation is
from athletes’ first post-concussion assessment.
20
Methodology: Procedures
• The ImPACT test (www.impacttest.com) was administered
to both samples of Athletes and Soldiers.
• The ImPACT measures short and long term memory
across single words and abstract visual stimuli in addition
to assessing learning.
• The Soldiers were administered the military version which
asks questions about the presence or absence of PTSD
symptoms. No pre-deployment data was available.
• The Athletes took the standard version of the ImPACT
test.
21
Nota bene…
• The second study is based on small
convenience samples, and will be reported as
a descriptive study.
• These samples were matched as closely as
possible for age, gender and education.
22
Athletes
Soldiers
9
7
M=6
M=7
F=3
F=0
N
Gender
Age
Mean 17.67
sd
Education
Mean 10.7
sd
Time Post
# of Concussions
1.7
1.7
Mean Days 7.2
30.14
6.26
12.86
1.1
Mean Months 14.4
Mean 1.0
2.3
sd 1.6
1.6
23
Athletes
Memory Composite
Verbal
Mean
sd
Visual
Mean
sd
Reaction Time
Mean
sd
Total Symptom Score
Mean
sd
Soldiers
79.56%
9.99
>
67.43%
10.26
64.33%
13.12
>
58.43%
9.64
.63 sec
.15
19.9
11.6
.66 sec
.05
<
53.3
18.3
24
• Analysis of performance on the ImPACT and the Total
Symptom Score indicated differences between the Soldiers
and matching sample of athletes.
• One year post-injury, the Soldiers demonstrated
impairments in cognitive-linguistic function, and higher
ratings on the Total Symptom Score than did the athletes.
• The athletes who were seen ≤ 2 weeks post-concussion,
reported significantly fewer indicators on the Total
Symptom Score.
Prue-Owens, 2008)
(Salvatore, Sirmon Fjordbak, Bene, Ponce de Leon, &
25
The next section reports PTSD and
Symptom data collected from
Athletes assessed at the
UTEP Concussion Management Clinic
26
27
Relationship between
Post-Concussion and PTSD Symptoms
• Preliminary investigation showed that Soldiers had
significantly higher Symptom Scores than Athletes.
• Soldiers also reported a number of PTSD symptoms,
but at the time of the first two studies, we did not
have data on self-reported PTSD symptoms in
Athletes.
28
PTSD Questions
1. Are you having nightmares?
2. Are you having flashbacks?
3. Are you having trouble keeping thoughts of the incident
out of your head?
4. Are you feeling numb or detached?
5. Are you avoiding similar situations?
6. Are you having difficulty sleeping?
Pts were asked to respond yes or no to each of these questions.
A yes response equals a score of 1 for the specific question.
www.impacttest.com
29
RESULTS
Athletes’ self-reported positive responses to
PTSD questions at Baseline (n = 145)
• Mean = .28
• SD
= .93
• Range = 0-6
This mean of .28 is similar to the mean of .44 reported
by the sample of 9 concussed athletes at baseline.
30
• At baseline, this sample of 145 athletes
reported an average of less than 1 positive
response to the six PTSD questions (mean =
.28).
• This measure would provide some insight into
the frequency of “free-floating” self-reported
PTSD symptoms in athletes prior to a
concussion.
31
32
Methodology
• Pre-participation baseline data was collected,
with follow-up testing after sustaining a
concussion in either practice or play. Athletes
were seen for serial re-assessment of
cognitive-linguistic function for the purpose of
monitoring recovery and contributing to
return-to-play decisions.
33
• We looked at our data on athletes who were
tested after concussion, and found that while
they reported symptoms of PTSD immediately
following the concussion, over the course of
recovery, these self-reported symptoms of
PTSD diminished.
34
RESULTS
• Post-Concussed Athletes’ self-reported PTSD
symptoms over time:
• N
• Mean
• SD
BL
PC-1
PC-2
PC-3
9
57
41
34
.44
1.3
.95
.67
1.50
1.30
1.09
1.01
35
RESULTS
• A sample of post-concussed athletes shows a
significant reduction in self-reported PTSD symptoms
from Post-Concussion 1 to Post-Concussion 2 to PostConcussion 3 on serial re-assessment.
• We only had BL-PTSD data on 9 of 85 athletes who
eventually suffered a concussion.
• So, there is PTSD data on 76 athletes who suffered a
concussion, but for whom we had no BL data.
36
RESULTS
• Post-concussion, athletes showed a reduction in positive
responses to the PTSD questions from PC1 through PC3.
• The average number of PTSD symptoms for the baseline
data (.28) is less than the average reported (1.3) at PC-1.
• However, the athletes showed increase in self-reported
PTSD symptoms after concussion from .44 to 1.3.
• As a point of comparison, Soldiers reported a mean of
3.35 PTSD symptoms at one year post-concussion.
37
When comparing Soldiers and athletes
diagnosed with concussion, the
manifestations are substantially different,
including presence and frequency of
co-morbid Total Symptom Score and selfreported PTSD symptoms.
38
• Differences:
– cause of the injury (hit versus blast)
– the etiological and localization manifestations (focal
versus global)
– history of previous concussion/mTBI
– context within which the injury was sustained (sport
versus war).
39
• Baseline data showed that athletes show few
pre-morbid signs of PTSD.
• Additional analysis showed that athletes do not
show persistent signs of PTSD post-concussion.
40
• Both the athletes and Soldiers reported concussion.
• The two groups differed in terms of Total Symptom
Score and response to PTSD questions.
• Soldiers at 1 year post-concussion/mTBI report
higher Total Symptom Scores, and respond
affirmatively to questions assessing the presence or
absence of PTSD symptoms.
41
• This data suggests that while the nature of the injury
to the brain is different in many cases between the
athletes and the Soldiers, specific indicators of the
pre-morbid presence of PTSD symptoms in Soldiers is
needed before any definitive conclusion can be made
about the correlation between cognitive linguistic
performance and PTSD symptoms between athletes
and Soldiers who have experienced concussion.
42
• The comparison points out:
– Even many months removed from the battlefield, the
Soldiers continued to present with cognitivelinguistic deficit profiles that were still more impaired
than those observed in athletes who were seen
within a few days of their injury.
43
• The comparison points out:
– When compared to soldiers, the athletes did not
report a comparable number of PTSD symptoms.
– in general, performance on measures of cognitivelinguistic function were qualitatively and
quantitatively different.
– most athletes recovered within two to three weeks
with appropriate care.
44
• The controversy surrounding the frequently co-morbid
diagnoses of PTSD and concussion remains unresolved.
• The data from the athletes suggests that the occurrence
of a concussion does not necessarily lead to persistent
symptoms of PTSD.
• Hoge et al. (2009) advocate for improved assessment
instruments, replacing the diagnosis of mTBI with
concussion, in an effort to prevent disability
classification based on inadequate evidence.
45
• Schneiderman and colleagues (2008) suggest that PTSD
should be considered along a spectrum of mild,
moderate, severe, in conjunction with descriptive
ratings of concussion injuries.
• Such classifications will lead to more accuracy in
differential diagnosis, as the label of concussion alone
may not be sufficient to describe the range of injuries,
comorbid diagnoses, and diversity of recovery patterns
observed in clinical settings.
46
Limitations:
• One of the significant differences between the
original two groups was the amount of time
post-injury at the time of measurement.
• Small sample sizes
• Lack of comparable baseline data for both
samples.
47
Acknowledgments
• Thanks to William Beaumont Army Medical Center for their
cooperation in this project.
• We are grateful to Lt Col Kathy Prue-Owens and her
research team for involving us in their work, and to Dawn
Hearn, ATC and the UTEP Athletic Department for their
support of the Concussion Management Clinic.
• SLP graduate students: Jackie Picone, Vanessa Fernandez,
and Attea Guidi.
• Sincere gratitude is extended to all
the participants.
48
•
Chan, RCK (2001). Base rate of post-concussion symptoms among normal people
and its neuropsychological correlates. Clinical Rehabilitation, Vol 15(3), 266-273.
•
Hoge, CW, McGurk, D, Thomas, JL, Cox, AL , Engle, CC & Castro, CA (2008). Mild
Traumatic Brain Injury in U.S Soldiers Returning from Iraq, New England Journal of
Medicine. 358 (5), 453-463.
•
ImPACT website; www.ImPACTTEST.com
•
Kennedy, JE, Jaffee, MS, Leskin, GA, Stokes, JW, Leal, F, Fitspatrick, PJ (2007).
Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms and
mild traumatic brain injury. J Rehabilitation Research & Development, 44, 895-920.
•
Lew, HL, Poole, JH, Vanderploeg, RD, Goodrich, GL, Dekelboum, S, Guillory, SB,
Sigford, B, Cifu, DX. (2007). Program development and defining characteristics of
returning military in a VA Polytrauma Network Site, Journal of Rehabilitation
Research & Development , 44 (7), 1027–1034.
49
•
McCrea, M, Guskiewicz, KM, Marshall, SW, et.al. Acute effects and recovery time
following concussion in collegiate football players: The NCAA Concussion Study,
JAMA 2003, 290, 2556-63
•
Salvatore, A. P., Sirmon Fjordbak, B., Bene, E.R., Ponce de Leon, M., & Prue-Owens,
K. (2008, July). Comparison of concussion in athletes and soldiers. Poster session
presented at New Developments in Sports-Related Concussion Conference.
Pittsburgh, PA.
•
Schneidermann, AI, Braver, ER, Kang, HK. (2008). Understanding Sequelae of Injury
Mechanisms and Mild Traumatic Brain Injury Incurred during the Conflicts in Iraq
and Afghanistan: Persistent Postconcussive Symptoms and Posttraumatic Stress
Disorder, Am. J. Epidemiol. (2008) 167 (12): 1446-1452.
•
Sundin, J., Fear, NT, et al., (2010). Psychological Medicine: A Journal of Research in
Psychiatry and the Allied Sciences, Vol 40(3), 367-382.
50