Treating Mild TBI – Mid-term report: Trying hard but could do better.
18th March 2022
By Caitlin Thompson, Assistant Psychologist & Dr Richard Maddicks, Consultant Clinical Neuropsychologist
As detailed in the previous blogs, the mild TBI (mTBI) literature is characterised by a lack of clarity regarding definitions, varying injury classifications and confounds associated with co-morbid conditions. Empirical studies regarding the treatment of mild TBI have inevitably reflect these dubitable foundations.
Current Psychological Treatment Methods
Historically, rehabilitation programmes for patients with an acquired brain injury have focused on cognitive deficits and associated behavioural problems. However, whilst these approaches might be transferable to patients following mTBI, their relevance is likely to be mediated by the nature/severity of symptoms and the heterogeneity of ‘post-concussive’ presentations. Over the past decade there has been an increase in research trials and systematic reviews on cognitive, psychological and medical interventions for preventing and reducing post-concussion symptoms in mTBI patients. Based on recent literature and what we know about clinical work in this domain, clinicians have relied heavily on reassurance, traditional education (e.g. head injury information and advice), with the most common and widely used psychological treatment for mTBI being Cognitive Behavioural Therapy (CBT). However, more recently, the ‘evolution’ of CBT has also been reflected in the mTBI treatment literature.
Cognitive-Behavioural Therapy
CBT is a ‘symptom focused’ psychological approach, aimed at improving self-management of symptoms typically associated with mild TBI presentations. These include anger, depression, anxiety and PTSD symptoms, all of which lend themselves to this treatment approach (Townsend et al, 2010). Evidence shows CBT can improve anxiety and depression symptoms at 1-month follow up trials and significantly improves headaches, insomnia and psychosocial functioning (Al Sayegh, A., Sandford, D., & Carson, A. J, 2010).
It is notable the best treatment results have been found when post-concussion programmes are targeted for people with an increased risk of persistent symptoms. Conclusions have suggested that a combination of psychotherapeutic approaches and counselling are more effective than education and reassurance treatment alone (Al Sayegh, A., Sandford, D., & Carson, A. J, 2010). A ‘multidimensional’ rehabilitation approach could provide some benefit by addressing the multiple interacting causal factors of persistent symptoms. Acknowledging psychological, emotional, behavioural, social/interpersonal and developmental factors on individual experiences allow for a more person-centred clinical approach. This aims to reduce symptoms and introduce management skills that are tailoured to the patient’s life and ‘bespoke’ rehabilitation programme.
Similarly, patients with FND have responded well to CBT and it remains the preferred treatment modality for patients with psychogenic nonepileptic seizures. Yet, the abstract nature of cognitive restructuring in CBT is inherently cognitively demanding, therefore, likely to be challenging for patients with cognitive impairments that compromise attention, working memory and information processing (Aeschleman & Imes, 1999; Kangas & McDonald, 2011). It is subsequently questionable why this therapeutic approach remains the preferred treatment method for this population.
Psychodynamic, Interpersonal or ‘insight focussed’ Therapies
CBT focuses on current cognitive and behavioural factors with less focus on historical and interpersonal ‘processes’. With decreased attention on the potential role of childhood adversities that can be a source of resistance in therapy, CBT can be more agreeable for some patients than psychodynamic therapies (PDT). The disadvantage of not addressing these factors in the patient’s treatment means that potentially important and factors maintaining symptoms could remain unaddressed (Gutkin, McLean, Brown & Kanaan, 2021). Conversely, whilst PDT focuses on the emotional and interpersonal aspects, this also may not be helpful to all patients as they may be unwilling to approach their problems from a ‘historical’ perspective. Future research into the suitability of CBT and PDT to different FND and mTBI ‘sub-groups’ could identify characteristics that can predict better responses to psychotherapy or guide selection of a particular treatment modality.
Acceptance & Commitment Therapy
While the ‘mechanism’ of persistent mTBI symptoms is still not fully understood, it is worth recognising the use of treatments that address symptom management, adjustment and behavioural ‘goals’. Over the past decade the Acceptance and Commitment Therapy paradigm has been researched and applied to the mTBI population and similar conditions, with increased attention on the patient’s values, behaviour change and psychological ‘flexibility’.
Acceptance and Commitment Therapy (ACT), a ‘second wave’ behavioural therapy, focuses on six key components that intend to employ the patient with key skills that aid long term management of thoughts and emotions to improve daily life (Kangas & McDonald, 2011). This therapy aims to change and reframe the function of psychological events to the individuals contextual and cognitive experiences with the use of mindfulness techniques. As a process-orientated approach, patients learn to engage in living a valued and purposeful life without the need for ‘cognitive restructuring’, commonly used in CBT. ACT has demonstrated promising effectiveness improving functionality and wellbeing in a variety of populations that have psychological disturbances and/or medical problems. Controlled studies have demonstrated that ACT is effective in treating depression and anxiety which are common post-concussive symptoms. Hayes and colleagues (2006) conducted a meta-analysis, finding that ACT, compared to other interventions such as CBT, was effective in assisting patients experiencing a range of psychological and somatic problems. The magnitude of this study was impressive with strong evidence of maintenance of therapeutic gains at long term follow ups.
No published study to date has tested the efficacy of an ACT intervention that incorporates all six key dimensions of the model with an acquired brain injury population. There is however, initial evidence to support the application of acceptance and mindfulness-based approaches for TBI patient groups. A 12-week group intervention using mindfulness-based stress reduction therapy and self-exploration of TBI-related disabilities provided some positive outcomes. At the end of the intervention, participants reported substantial improvement in overall quality of life and reduced depressive symptoms compared to patients’ who did not complete the study (Bédard et al, 2003).
ACT has been recommended for distressed patients who experience at least moderate anxiety, stress or depression in response to mTBI. It has been deemed less appropriate for highly distressed and those reporting suicidal ideation, require more specialised psychiatric treatment. This intervention also might not be suitable for patients with certain cognitive impairments or limited ‘self-knolwedge’, as there is a level of self-awareness needed to implement the six core dimensions. Further research into the effectiveness of ACT as a treatment method for mTBI patients is essential to inform appropriate clinical guidelines for patients that would respond best to this treatment method.
Individual Differences
Clinical opinions are polarised regarding whether post-concussion symptoms are a result of neurogenic factors (residual neurological effects of the original mTBI) or psychogenic factors (pre-morbid psychopathology or personality characteristics) (Prince & Bruhns, 2017). It is possible that clinicians could fall into a false sense of confidence in ‘stand-alone’ or parochial approaches which might fail to address patients’ broader social, medical and needs and could lead to ‘sub-optimal’ treatment. As the literature generally supports the multifactorial aetiology of persistent mTBI symptoms, biopsychosocial models might have particular relevance to treatment approaches. The biopsychosocial model has therefore been shown to be likely to have ‘significant application to the management of concussion and post-concussion headaches’ (Register-Mihalik, J. K., DeFreese, J. D., Callahan, C. E., & Carneiro, K, 2020).
It is recommended in acquired brain injury rehabilitation to implement a person-centred approach to treatment, involving the client in the planning and evaluation to empower active participation in their own care (Brett, Sykes, & Pires-Yfantouda, 2017). ‘The involvement of patients in clinical decision making is recommended in the management of long-term conditions’ such as mild TBI (Holliday, Cano, Freeman & Playford, 2007). Moreover, how people choose to report their symptoms can also be influenced by prior injuries/health difficulties, personality factors and the possibility of future financial gain. Therefore, concerns remain surrounding the over/under reporting of symptoms and associated diagnosis, leading to inappropriate or gratuitous treatments, based largely on subjective recall. Recent debate of definitions has suggested the importance of clinicians distinguishing between objective and subjective symptoms with an emphasis on observable signs (Silverberg et al, 2021).
However, despite some positive evidence for the use of CBT with this group, there is currently no consensus on the treatment protocol for this population. Treatment guidance for clinicians working with patients with mild TBI remains limited affecting researchers and practitioners’ ability to confidently recommend the use of one treatment over another at this time. A systematic review of treatment outcomes of mTBI struggled to recommend the use of any types of treatment due to a lack of good quality evidence and concluded that ‘no single currently published treatment intervention can be unequivocally recommended’ (Arbabi, M., Sheldon, R. J. G., Bahadoran, P., Smith, J. G., Poole, N., & Agrawal, N, 2020).
Acknowledging the complexity of treatment for the population of mTBI patients with persistent symptoms presupposes a flexible approach to treatment methods with, where possible, proven efficacy of symptom reduction. There is still a need for further research into the value of psychotherapies such as CBT and ACT to ‘subgroups’ within the mTBI population, to establish treatment efficacy for differing symptom presentations. For example, mindfulness-based therapies could enable certain patients to adjust to unusual, persistent or worsening symptoms, promote improved long-term symptom management and increased self-efficacy. Clinicians therefore should often adopt a multidisciplinary, patient-centred approach to adequately assess and treat individuals needs, regardless of uncertain aetiology.
Future Directions
As outlined in previous blogs, the lack of understanding regarding the aetiology of mTBI symptoms is likely to necessitate reference to a broad range of models and approaches. Correspondingly, the complex interplay of biological, psychological and social factors is likely to influence how patients understand and ‘express’ their symptoms and mediate their response to treatment(s).
Despite individual’s differences and varying attribution of symptoms, psychological intervention/psychotherapy remains a core component of treatment plans for mTBI. However, it is possible that certain patients will perceive the recommendation of psychological treatment as dismissive or incompatible with their needs. It also remains unclear whether a combination of psychological interventions is superior to one therapeutic model or education and reassurance alone. It is therefore important to consider the evidence for alternative interventions that prove to be effective in the reduction of complaints, increasing engagement in daily activities and improving the patient’s wellbeing. These approaches clearly need to address persistent symptoms, associated disorders and individual differences to provide optimal and lasting treatment gains.
Further research into different psychotherapeutic treatments needs to be considered in order to build confidence in efficacy and support clinical decision making. A lack of consensus regarding diagnosis and the subjectivity of many symptoms could present challenges to treatment research. However, it is possible that improved patient assessment and ‘selection’ could assist in evaluating treatments with different patient groups as opposed to the assumption of homogeneity or consistency.
Constraints on statutory service provision are inevitably likely to impact the further development of integrated assessment and treatment ‘pathways’ for patients with mild TBI, however, further clinical clarity in diagnosis and treatment could assist in driving innovation and development. Moreover, resources should also necessarily be targeted at the identification of ‘at risk’ patients to facilitate early intervention and identify those most likely to benefit from further investigations and treatment approaches. Similarly, studies of treatment efficacy should build upon our existing knowledge of the contribution of broader psychological factors including attributions, adjustment, anxiety and iatrogenic effects. The cost-effective use of resources will, as ever, be determined by research identifying applicable treatment methods that improve patients’ understanding of often odd, overwhelming symptoms, increase their self-efficacy/wellbeing and develop confidence in their ability to adjust their lives and pursue meaningful activities and goals.
References:
Aeschleman, S. R., & Imes, C. (1999). Stress inoculation training for impulsive behaviours in adults with traumatic brain injury. Journal of Rational and Emotive Cognitive Behavior Therapy, 17, 51–65.
Al Sayegh, A., Sandford, D., & Carson, A. J. (2010). Psychological approaches to treatment of postconcussion syndrome: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry, 81(10), 1128-1134
Arbabi, M., Sheldon, R. J. G., Bahadoran, P., Smith, J. G., Poole, N., & Agrawal, N. (2020). Treatment outcomes in mild traumatic brain injury: a systematic review of randomized controlled trials. Brain injury, 34(9), 1139-1149
Be´dard, M., Felteau, M., Mazmanian, D., Fedyk, K., Klein, R., Richardson, J., Parkinson, W., & Minthorn-Biggs, M-B. (2003). Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disability and Rehabilitation, 25, 722–731.
Brett, C. E., Sykes, C., & Pires-Yfantouda, R. (2017). Interventions to increase engagement with rehabilitation in adults with acquired brain injury: A systematic review. Neuropsychological rehabilitation, 27(6), 959-982.
Gottshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation, 29(2), 167-171.
Gutkin, M., McLean, L., Brown, R., & Kanaan, R. A. (2021). Systematic review of psychotherapy for adults with functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry, 92(1), 36-44.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44, 1–25
Holliday, R. C., Cano, S., Freeman, J. A., & Playford, E. D. (2007). Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit. Journal of Neurology, Neurosurgery & Psychiatry, 78, 576-580.
Kangas, M., & McDonald, S. (2011). Is it time to act? The potential of acceptance and commitment therapy for psychological problems following acquired brain injury. Neuropsychological rehabilitation, 21(2), 250-276.
Nampiaparampil, D. E. (2008). Prevalence of chronic pain after traumatic brain injury: a systematic review. Jama, 300(6), 711-719.
O’Neal, M. A., & Baslet, G. (2018). Treatment for patients with a functional neurological disorder (conversion disorder): An integrated approach. American Journal of Psychiatry, 175(4), 307-314.
Prince, C., & Bruhns, M. E. (2017). Evaluation and treatment of mild traumatic brain injury: the role of neuropsychology. Brain sciences, 7(8), 105.
Register-Mihalik, J. K., DeFreese, J. D., Callahan, C. E., & Carneiro, K. (2020). Utilizing the biopsychosocial model in concussion treatment: Post-traumatic headache and beyond. Current Pain and Headache Reports, 24(8), 1-7.
Silverberg, N. D., Iverson, G. L., Arciniegas, D. B., Bayley, M. T., Bazarian, J. J., Bell, K. R. & Whitehair, V. (2021). Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury. Archives of physical medicine and rehabilitation, 102(1), 76-86.
Townsend, E., Walker, D. M., Sargeant, S., Vostanis, P., Hawton, K., Stocker, O., & Sithole, J. (2010). Systematic review and meta-analysis of interventions relevant for young offenders with mood disorders, anxiety disorders, or self-harm. Journal of adolescence, 33(1), 9-20.