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.

Sleep disturbance Inactivity, particularly in an athlete Affective disorders Malingering/Factitious Disorder Persistent physical injuries Pain Substance use/abuse Somatoform disorders Family dynamics Misinterpretation of cognitive data 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. Adequate amount of sleep but no more naps! Consistency of sleep/sleep routines No reading/watching TV/computer use in bed Break after last cognitive activity Temperature and light exposure Caffeine intake and food choices Removing electronics from bedroom Use of melatonin/OTC sleep aids Get out of bed after 45 minutes awake 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- feigning or exaggeration of symptoms for financial gain Factitious disorder- feigning or exaggeration of symptoms for secondary gain

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)

Pain- How does it impact cognitive symptoms Pain- How 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!