Dr. Scott Sperling

Welcome to Meet the Authors, a podcast brought to you by a collaboration of the Society for Clinical Neuropsychology and the journal, Neuropsychology. My name is Dr. Scott Sperling and I’m grateful to be your host.

In this podcast, student leaders in neuropsychology will discuss prominent recently published studies with the authors who undertook the research, allowing for a behind-the-scenes look into the development, implementation analysis, and future implications of cutting-edge neuropsychology research. Today, our student leader, Dr. Elaine Schultz, will be discussing an exciting paper entitled, Psychometric Properties of Two Instruments Assessing Catastrophizing and Fear Avoidance Behavior and Mild Traumatic Brain Injury, with two of the paper’s authors, Skye King and Dr. Melloney Wijenberg.

I’d like to now introduce our student leader and esteemed guests. Dr. Elaine Schultz completed her PhD in clinical psychology at Rosalind Franklin University and is completing her postdoc in neuropsychology at the Michael E. DeBakey VA Medical Center in Houston, Texas. Her clinical interests include providing neuropsychological and therapeutic care for individuals who have experienced brain injury, primarily in rehabilitation settings, and her primary research interests relate to how personality characteristics influence symptoms and recovery post-brain injury and how PTSD and poor sleep impact physical and cognitive functioning.

Welcome Dr. Elaine Schultz.

Dr. Elaine Schultz:

Excited to be here.

Dr. Scott Sperling:

And our esteemed authors here. Ms. King is a third year PhD candidate at the University of Maastricht in the Netherlands. Her current research focuses on developing and investigating an intensive exposure intervention for patients with persistent post-concussion symptoms following mild traumatic brain injury. She obtained her master’s degree in clinical neuropsychology from Leiden University and her master of philosophy and psychology at Monash University South Africa.

Our second author here, Dr. Melloney Wijenberg, works as a healthcare psychologist in training at Adelante Rehabilitation Center in Limburg. She obtained her PhD in the field of neuropsychology, during which time she investigated the cause and treatment of persistent complaints after mild traumatic brain injury at the Limburg Brain Injury Center. She has held several clinical neuropsychology teaching positions for students, healthcare psychologists in training and occupational therapists.

So welcome, Ms. King and Dr. Wijenberg.

Ms. Skye King:

Hi, nice to be here. Thank you for the invitation.

Dr. Melloney Wijenberg:

Yeah, thanks for having us.

Dr. Scott Sperling:

Absolutely. And I’ll now turn our conversation over to Dr. Schultz.

Dr. Elaine Schultz:

Great. So in their paper, the authors examine the psychometric properties of the post-concussion symptom catastrophizing scale, or PCSCS, and the fear of mental activity scale, FMA, in individuals with mild traumatic brain injury to determine if these measures could be used in research and clinical practice to explain prolonged recovery following mild traumatic brain injury. So, for those who may not have yet read your paper, can you briefly summarize the main findings of your study?

Ms. Skye King:

Yes, sure. So, as you suggested, we aimed to investigate the psychometric properties, including the factor structure, the internal consistency, test-retest reliability and concurrent and construct validity of two adapted questionnaires which are the PCSCS and the FMA in a sample of participants with mild traumatic brain injury and we compared this to participants with orthopedic injuries and also to healthy adults. And what we found was that after going through confirmatory factor analysis we found that the factor structure for the PCSCS was best as a three-factor structure that had magnification, rumination, and helplessness as it’s three sub-factors, and that it also had a higher order factor which was catastrophized. We then also found that the factor structure of the FMA was best as a two-factor structure, and this was what we termed activity avoidance and somatic focus. We also found that both of the questionnaires had really strong internal consistency and test-retest reliability, and that there was good validity as well. So, these findings show us that both of these questionnaires would be useful and we think that they would have good utility in clinical research and also in research for not only mild traumatic brain injury, but also in maybe other samples that have similar complaint.

Dr. Elaine Schultz:

Great, thank you so much for that explanation. Some questions that we had for you. We were curious about the rationale behind choosing to administer the measures two weeks post-injury. Do you think that these measures would be more useful in regards to prevention or prevention tools in acute settings or in sub -acute settings? Or if there’s utility in using these measures to treat chronic post-concussion symptoms additionally?

Ms. Skye King:

So, firstly, the rationale behind two weeks, I think, was that right after injury, you can start to see some of these symptoms as a normal progression and that some of these complaints that people get are completely considered normal. Over time, they can become problematic and persistent, especially when we have things like increased avoidance of activities, increased fear and increased symptom catastrophizing. So, there was the rationale behind doing the two weeks was to also check kind of what the variability and variation at two weeks and later on would be for the measures themselves. So, I think that there’s utility utilizing them at all the different stages along recovery.

Dr. Melloney Wijenberg:

I can maybe add a little bit on that because what is also very important when you perform research, right, that it has to be implemented in the clinical facilities the patients are. So, in the Netherlands, when you have a concussion or when you have a orthopedic traumatic injury, which were the two groups, right, we saw also the healthy ones, but I’m now focusing on the two clinical groups, they are administered at the emergency department. And there is no time to do questionnaire there. And you also have the problem of getting consent, right? And stuff like this. So, what we did is we asked them, are you interested in doing research? And if so, that’s great. Then I will contact you as a researcher afterwards when you’re already at home, right? Because those patients were directly sent home after the emergency department thing. And then in the Netherlands, you also have to have some time to think if you really want to participate in research. And we also wanted to make sure that the follow-up, we had a lot of follow-up afterwards, right? So, the data we used, it was a three-month data for this article, right? We actually followed them even longer. So, we really wanted to make sure that the loss of data over time was minimal. So that’s why we actually went to the people for the first assessment. So, we went visit them at their houses or they came to the university, what they preferred, to have them have a face and not only a digital questionnaire to make the motivation as large as possible. And this was feasible in the first two weeks. So, this is why we did a two-week postmark. But I think from a more theoretical point, it would be also really nice to already see this right at the emergency departments, right? Because we know that this behavior and thoughts also happen at healthy people. Our data also showed that. So, in that sense, it would be really nice to just see at when you have this, what is then your score on these questionnaires? And now we have some data of these questionnaires, of course, can you maybe then predict stuff? Can you maybe explain stuff, what you see.

Dr. Elaine Schultz:

Great. Thank you for that explanation. I think that leads into my next question pretty well. So, at a U.S. Veteran Affairs Hospital, I work with a large number of patients who have functional and vocational challenges following mild traumatic brain injury. Whether or not that’s things like re-engaging within the community or completing activities of daily living or returning to work. We were curious, might the PCS /CS or the FMA have predictive value in determining possible long -term functional outcomes in individuals with mild traumatic brain injury?

Ms. Skye King:

So that’s really interesting because I’m currently also working on the same data set as Melloney suggested. We did a long-term follow-up of these participants and we’re also looking at if they have predictive quality or predictive utility for these persistent complaints. And what we are actually finding is that catastrophizing and this avoidance of activities is predictive of long-term symptoms, long term complaints. So, I think that these measures would be useful in those types of populations also for treatment outcomes or to get rehabilitative help at the right time.

Dr. Elaine Schultz:

That’s great. I love to hear that, of being able to use that to predict long-term outcomes. That’s awesome. Our next question is individuals with a history of antidepressant medication use were excluded from your study. And so given that patients with mild traumatic brain injury and persistent post-concussive symptoms often have comorbid or pre -existing psychiatric conditions, do you think that these results would still be applicable to individuals with pre-existing mental health concerns?

Dr. Melloney Wijenberg:

Yes, that’s a really nice question, right? Of course, with research in clinical questions, it’s always a question like, is our sample most representative for our clinical sample, or can we do really good research with it? Because what you really want to know is if the findings you find, do they relate to the factor you are interested in? In this case, this was of course a TBI versus a traumatic injury versus healthy or has it to do with other factors that we are already known to have influences on these scores. And a human is more complex than that, right? But you have to choose what are we going to really exclude and whatnot. So with antidepressants, yes, we said that that’s indeed an exclusion beforehand but afterwards it was not necessary because this was also really what we wanted to know right so we know that people after traumatic brain injury can get depression and also antidepressants are the treatment form and we did not exclude on psychological history because already when we started our study it was a well-known predictor so we did ask this do you already have from psychological history, yes or no, so that we also have this predictor in our study. But with the antidepressants, we thought it was quite difficult because it also really has an influence, of course, on the brain and what’s the timing of your antidepressant start, right? Is it a stable dose or not? When did you start stuff like this, made it more tricky for us?

Dr. Elaine Schultz:

Yeah, I think that’s understandable, when you’re trying to be clean and address the data and like you mentioned the factors that come out of these measures. So, thank you for that clarification. We are also curious how might additional measures such as neurocognitive or psychological assessment enhance the understanding of the relationship between catastrophizing about symptoms and fear avoidance behaviors in individuals with mild traumatic brain injury?

Ms. Skye King:

I definitely think that neurocognitive testing, but also psychological testing and also other variables we do see are predictive of persistent symptoms or these persistent complaints over time. And those include things like coping style and other things as well. In our data, we did collect lots of other variables and hopefully we’ll be able to share soon in a publication what the whole model looks like with all of these variables taken into account as well, but we can see that there are other contributing factors. These two factors don’t only contribute to these symptoms, but they do play a major role. And what we’ve also seen is that therapeutically these two things can also be changed or affected in a positive way, and that can often change the direction of these persistent symptoms as well.

Dr. Melloney Wijenberg:

Yeah, I completely agree with Skye, so I think it is very exciting to think of it like, “Oh, should we do it as complete assessment and always look at these variables?” I don’t think the treatment and even in the future, the treatment that will arise for MTBI patients, that it will be like one treatment for all, right? So yeah, the data that already is collected all over the world and analyzed and now are studying maybe for a next publication. We’ll add to that, but it is good to know that this is a valuable factor and that it’s good to assess this, but you shouldn’t forget all the rest. I think that would calm your assessment of a psychologist in clinical care, but you can definitely maybe improve it to take this into account.

Dr. Elaine Schultz:

Yeah, I agree and I look forward to reading that future literature. So, we also really appreciated your discussion regarding potential limitations in the generalizability of your results given that racial demographics were not collected within the study design and that there were significant differences in sex and education levels between samples. And so, what recommendations might you have for future validation research of the PCSCS and/or the FMA in diverse mild traumatic brain injury patient populations?

Ms. Skye King:

So, I would definitely suggest that future research look into attempting to replicate these findings in a more diverse sample that could be stratified and maybe randomly sampled as well and be more representative of the type of populations that you would see in clinical care potentially, if that’s where the utility is going to be that you have nicely randomized and stratified samples to allow for these variables maybe to not have so much of an influencing factor that they did in our study.

Dr. Melloney Wijenberg:

Yeah, and I think that would be amazing if that’s possible. And especially if you look into the constructs of catastrophizing and fear avoidance, I think actually that this is very culturally influenced and also has to do with the medical doctor tells you when you visited the emergency department how your spouses respond to the fact that you just had a concussion. What is the cultural idea of if you have an illness or not or if you have some symptoms or not? How is the medical care the follow-up? Is there a follow-up or not? This all influences this disease process we think that maybe has an influence on developing chronic symptoms and for other people they don’t develop these chronic symptoms. So, culture is a very important thing, and I would be very interested if we now publish these questionnaires, if people are using them at other countries where we didn’t of course validate them, we validated them in the Netherlands, and if they are able to also validate them in other countries, that would be amazing, right? To see if it’s indeed also applicable for other countries and cultures.

Dr. Elaine Schultz:

Well, thank you, Ms. King and Dr. Wijenberg, for discussing your study and sharing your expertise in this important area of research. And I will now turn it back over to our host, Dr. Sperling.

Dr. Scott Sperling

On behalf of the Society for Clinical Neuropsychology and the journal, Neuropsychology, I’d also just like to extend my gratitude to you, Dr. Schultz for hosting this podcast. And then certainly to Dr. Wijenberg and Ms. King for not just taking the time to discuss this research with us, but for conducting the research in and of itself. It really is a fascinating line of work. You know, as you discussed, we’ve known for quite a long time now that preexisting psychiatric factors, you know, have a role in terms of post -injury outcomes. But your work, I think really extends that pre-existing knowledge and really getting into these really interesting variables around fearlessness and catastrophizing, and I agree with Dr. Schultz, I very much look forward to reading your future papers and understanding the magnitude of the impact of these variables and their potential interactive effects if we’re going to be able to more effectively tackle the treatment of these individuals moving forward, that only really stems from understanding the true underlying factors that precipitate the quote-unquote “negative” outcomes. So, I see your work as being very important to future care for large populations of individuals. So again, thank you for this excellent research and for taking your time to share sort of a deeper dive with us today.

Ms. Skye King:

Thank you so much.

Dr. Melloney Wijenberg:

Thank you.

Dr. Scott Sperling:

All right. Thank you all and take care.