Persisting Symptoms


Q: What are the top three things that therapists could do in cognitive behavioral therapy?


Question:

Shelly Massingale, PT, MPT: “So there was another question about a lot of us on here are therapists and we may not have access to neuropsychology or psychologists. So, what would be your top three things that therapists could do to help these patients? Is there really basic CBT training is one question that was asked.”

Answer:

Jamie Pardini, PhD: “So when somebody asked that question, I actually did a little quick search and there are conferences that are PT/OT based that do have speakers that come in and talk about basic CBT principles. There are also online webinars that talk about it a little bit. And even the Beck Institute offers a course for other disciplines to understand the basics of cognitive behavioral therapy. So I think you don’t want to be that kind of therapist, but understanding the importance of how and you already do this. So it’s kind of like rephrasing it.

So understanding how to explain to people that emotion affects behavior affects how you think. So when I have a headache, I think, “I’ll never get over this concussion, I’ll never be back to normal, this is terrible.” And then the minute I think that, I go eat a bag of potato chips, and then I feel horrible about myself, because I don’t have any self-control and well, now, I’m going to be overweight and I can’t control this. And it’s just this spiral of no matter where you start, the behavior or the emotion or the thought, we get wrapped up in that. And the goal of CBT is to find multiple places and multiple ways to address that. So I think just having some basic training and just looking for those opportunities in a general therapeutic way.”

Stanley Herring, MD: “Yeah, Shelly, I have an analogous situation with most of physical therapists. I’m not a mental health provider, but I find it my responsibility to try to set the patients up for success. So I think for physical therapists, the first thing to do is you have to know the material. This is not a topic for dilettantes. So understand, know all the material about recovery for mild traumatic brain injury and the timeline in which it happened. Second thing is I think physical therapists and physicians can be helpful in the unlearning process. So ask the patient in their own words to explain to you what the matter with him is, and then help them understand which parts of that may be grounded in fact and which may be belief systems that they can work upon. You do that while continually validating their suffering.

And then the third thing you do is know your business, that it is safe to do early activation. It is safe for them to go outside, to do some scores. They’re not going to damage their brain more if they read a book. If you want to delve into the world of Jamie and Donna and they’ve spent a lot of time getting good at it, I’m careful not to overstep my boundaries. You also have to understand it changes your role. You cannot be a healthcare provider and a therapist. It’s two different roles. If you want to start exploring those questions, I know everybody says they don’t have access to mental health providers. Go find one that knows this, go find your Jamie or Donna, and sit down with them and ask them what you can do to help the patient. They’re the experts. So what questions can I ask, what part of CBT would you be comfortable with me doing, and then I know everybody says it’s hard to find a mental health provider, but look harder. If your practice is full of these patients, you’re not going to get them better by yourself.”

Faculty:

Donna Broshek, PhD, ABPP-CN, Stanley Herring, MD, Jamie Pardini, PhD, Shelly Massingale, PT, MPT, & Bridgett Wallace, PT, DPT

Q: What is the timeframe to start using the diagnosis of persisting symptoms?


Question:

Shelly Massingale, PT, MPT: “When do you start using this diagnosis? So is there a time frame that you would say that somebody is now having persisting symptoms, or is it something we now think about all the time and change the way that we’re even speaking to our patients? I feel like that’s the answer, but is there a time frame that you all, as a group, were thinking to utilize this?”

Answer:

Donna Broshek, PhD, ABPP-CN: “Well, I just wanted to I say, I think that’s a very interesting and spot on question because we’ve been discussing that. I think one of the challenges is that may be a different time point for different patients. So part of that depends on the mechanism of injury. If it was an injury sustained from a chest-to-chest impact during a pickup basketball game, that trajectory could be very different than somebody who was in a high speed motor vehicle collision or a football player who’s had multiple, multiple concussions. So I don’t know that there really is any cookie cutter answer to that. I think it’s when you look at this patient and you’re starting to think, gosh, they’re not getting… First of all, if they’re not getting better at all, we know after concussion people get better. So if they’re not getting better or they’re getting worse, we know what the recovery curve of concussion looks like, and it goes like this. And if it starts to go like that, there’s another factor or something is going on. So I think looking at the recovery trajectory, and I think for that individual patient, if it’s a low speed, relatively uncomplicated first concussion, typically they start getting better, if it’s an adult, within a couple of weeks. And if they’re six months out and still saying, well, that’s a problem. And then of course there’s a big gap in there. I think one of the most important issues is to really try proactively to prevent persisting symptoms, which is education, education, education immediately. And sometimes that’s correcting this information because sometimes people come out of the emergency department with horrific information. You just had a horrible head trauma, you shouldn’t do anything at all for two weeks, and now you may have increased your risk for CTE. Those things are in medical records. And so it’s really important to provide corrective information and reeducation and sometimes directly address misinformation that the patient has been given. So I think all of that, individual recovery and then proactive education and trying to prevent those persisting symptoms.”

Faculty:

Donna Broshek, PhD, ABPP-CN, Stanley Herring, MD, Jamie Pardini, PhD, Shelly Massingale, PT, MPT, & Bridgett Wallace, PT, DPT

Q: Is there a somatosensory catastrophizing scale that can be used across patient populations i.e. pain vs head trauma vs dizziness?


Answer:

Stanley Herring, MD: “If I can ride the coattails of Donna and Jamie, I hope so. I know that we’ve talked about it, and I’m also working with some other groups where we are actually trying to validate pain catastrophizing scales and fear avoidance scales in this population. So I don’t think it’s there yet. I do think though that, as Jamie said, it was very interesting to hear Jamie. For each of her visits, she uses an anxiety and depression scale. Now she’s treating concussion, alleged concussion patients. So I think, and I’ll defer to my two colleagues, but we also use a depression scale and an anxiety scale, and we’re starting to introduce in the office a fear avoidance scale as well. So Bridget, they may not be validated, but I’m becoming increasingly comfortable with using them because it helps direct treatment. So let me let my more qualified colleagues answer that question correctly now.”

Jamie Pardini, PhD: “The only reason that we use the PHQ-9 and the GAD-7, because it does have a lot of overlapping experiences with concussion, is it’s brief and it’s free. And it gives you a tiny little window into how you might want to proceed further when people are answering, particularly some of the more emotional aspects of the symptoms in that inventory. You know, if I had my druthers, it would be a part, and I kind of made one and I haven’t used it yet, part catastrophizing, part kinesiophobia, part cogniphobia… But you kind of, in your practice, have to figure out what can I get away with and still, in terms of instruments, and still have time to talk to the patient and to treat the patient.”

Faculty:

Donna Broshek, PhD, ABPP-CN, Stanley Herring, MD, Jamie Pardini, PhD, Shelly Massingale, PT, MPT, & Bridgett Wallace, PT, DPT

Q: What advice do you have on how to talk to the patient when I no longer suspect the symptoms are from the concussion?


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Question:

Shelly Massingale, PT, MPT: “Oftentimes, I’m suspecting that a patient’s symptoms are no longer from the concussion. However, I find it difficult to have that discussion because the concussion gives them something to, quote, ‘blame’ for their symptoms. Any suggestions on how to have this conversation?” And I think any one of the three of you could answer her. Donna, would you be able to answer that?”

Answer:

Donna Broshek, PhD, ABPP-CN: “Well, I can try. You noticed that all three of us were nodding our heads. That is certainly a challenge that occurs. And what I try to do is really sit with the patient and try to understand what it is that is not working for them. And often, there’s something else in their life that they are unhappy about, or that is causing them suffering, and they’re putting it on to the concussion because it’s easier to put it on the concussion than to deal with some of the very, very difficult life circumstances they may have. And sometimes this is quite a process.

And for those of you not trained in psychotherapy, it may be just trying to introduce that and to encourage them to pick something that they’re going to work on to start to move forward, because it can feel overwhelming if they’re blaming or attributing, I shouldn’t say blame. Attributing so many things to the concussion. And so to really try to say, “What is the number one symptom that is…” Get back to the symptoms, “What is the number one symptom causing you the most problem? Let’s just focus on that, and work on moving you forward with that symptom. But it often requires multiple sessions, and potentially some psychotherapeutic intervention. But for any specialty, “What is the number one symptom causing you the most suffering that is most holding you back right now? And let’s see if we can make that symptom a little bit better.” Again, trying to instill hope that they can make progress and that they can move forward. And Jamie and Stan may have some other thoughts on that.”

Stanley Herring, MD: “Let me talk about how I can convince my patients to accept this. And Donna and Jamie are right there. When the patients have this, the integral part is to get them to agree to treatment. So the first thing I do is I validate their suffering. I say, “I understand your suffering. I understand you’re miserable, and in no way are you making up your symptoms. You’re not crazy,” or all the things they’d been told. And I say, using the chronic pain model, I say, “You know what, in times of chronic pain, the way that your brain interprets signals from your body has been altered. And treating this with traditional measures doesn’t work. It’s like giving someone the wrong antibiotic. So what you’re doing is not working. It doesn’t diminish your suffering. I believe you, but we need to look at this differently. And I can’t do that by myself.” That’s the way I set it up.”

Jamie Pardini, PhD: “And something I might add is that, sometimes if I’ve known them, I can say, “Here are some things that I believe are getting in the way of your recovery, or moving your recovery along.” And then I provide examples of what I think that is, and then how I think that we can work on it. So I think a while back, I noticed one of the questions about how you bring up the good old days bias thing, use it all the time. And I talk about that study. And I say, “When we’ve talked so far, you said never had a memory problem. I’ve never had a headache. That’s just so unusual for that to happen. And when you look at studies of people who are suffering, who are injured and they reflect back on their life before, there is this kind of wistfulness about how things used to be. And we all do that when we fall on hard times for a variety of reasons. And so part of this may be kind of looking backwards instead of looking forward. So rather than talking about who I was five years ago, let’s talk about how we’re going to move forward in the next three months, or how are you going to move forward in the next four weeks?” So I kind of introduce it like that as well.”

Faculty:

Donna Broshek, PhD, ABPP-CN, Stanley Herring, MD, Jamie Pardini, PhD, Shelly Massingale, PT, MPT, & Bridgett Wallace, PT, DPT



RESOURCES & LINKS:



FACULTY BIOs:

Donna Broshek, PhD, ABPP-CN

Donna Broshek, PhD, ABPP-CN, is the John Edward Fowler Professor of Psychology. She directs the Neurocognitive Assessment Lab and co-directs the UVA Acute Concussion Evaluation Clinic. Although she sees patients with multiple medical and neurologic issues, her clinical and research interests focus primarily on epilepsy and sports concussion. She is on the professional advisory board for the Epilepsy Foundation, is past-president and board member of the Sports Neuropsychology Society, and is a member of the NBA Concussion Committee. Dr. Broshek is also a founding member of the executive committee of the International Congress for Athlete Brain Health. 

Stanley Herring, MD

Stanley A. Herring, MD, is senior medical advisor and co-founder of The Sports Institute at UW Medicine, Co- medical director for Orthopedic Health and Sports Medicine for UW Medicine, and co-medical director of the UW Medicine Sports Concussion Program. Dr. Herring is one of the team physicians for the Seattle Seahawks and the Seattle Mariners. His clinical practice focuses on the diagnosis and non-operative management of neurological and musculoskeletal injuries, particularly focusing on spinal disorders in active people and athletes as well as sports-related concussions. Dr. Herring is a clinical professor in the Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery at the University of Washington, Seattle and holds the Zachery Lystedt Sports Concussion Endowed Chair. His philosophy is to provide kind and compassionate care that focuses not only on the relief of pain and suffering, but also helps patients return to activities that give them quality of life.

Jamie Pardini, PhD

Dr. Jamie Pardini is a Neuropsychologist and Clinical Associate Professor at the Sports Medicine and Concussion Specialists division of Banner University Medical Center-Phoenix. Prior to arriving at Banner, Dr. Pardini was Assistant Professor and Neuropsychologist for the Department of Neurological Surgery at the University of Pittsburgh Medical Center. She began her post-doctoral fellowship and academic career at the University of Pittsburgh Medical Center Sports Medicine Concussion Program, where she spent more than 9 years working solely with sport-related concussion and mild traumatic brain injury, managing the care and return-to-play of thousands of athletes.

Shelly Massingale, PT, MPT

Shelly Massingale is the Service Line Administrative Director for Sports Medicine at Banner in Arizona. She is a specialist in vestibular and balance therapy. Shelly has been practicing physical therapy in the outpatient neurological setting for 22 years and has specialized primarily in mild traumatic brain injury since 2013. Since opening the Banner Sports Medicine and Concussion Center in 2013, she has focused her treatment and research solely on concussion. She is a co-developer of the Concussion Balance Test (COBALT) and has published articles that explored the utility of COBALT as an objective measurement of balance for the healthy and injured athletic population. 

Bridgett Wallace, PT, DPT

Bridgett Wallace, PT, DPT, has a doctorate of physical therapy and holds competency-based certifications in vestibular rehabilitation and concussion management. Dr. Wallace has been treating patients with dizziness and balance disorders for more than 20 years and is the founder and President of 360 Balance & Dizziness – a specialty clinic for the evaluation and treatment of dizziness and balance disorders that includes both audiology and therapy services. She is also the co-founder and Director of Clinical Education for 360 Neuro Health Institute, which provides online, mobile and live educational offerings for health care providers.