Post-concussion care needs to be holistic: Professor Nada Andelic

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Table of contents:
[02:23] Nada Andelic
[05:10] Integrated care for post-concussion syndrome
[06:34] Post-concussion outcomes in men and women
[10:03] Return to work with or after a concussion
[13:57] Tele-rehabilitation for post-concussion care
[15:45] Post-concussion care: psychological work
[17:22] Holistic care is the future for PCS 

Introduction to this episode on post-concussion care

Post-concussion care is long past due for an overhaul! That’s Professor Nada Andelic’ strong statement, backed by the holistic system of care she and her colleagues have already implemented at the medical center of the University of Oslo

In this Concussion Stories episode, Professor Andelic shares her vision about comprehensive healthcare Melanie, and points out problems with and solutions for gender inequality, medical help with returning to work and psychological recovery from post-concussion syndrome. 

Before we start, I’d like to explain 2 terms we mention a lot. mTBI or mild traumatic brain injury is just another term for concussions. CENTER-TBI is one of the 3 largest ongoing research projects worldwide researching traumatic brain injuries, and concussions are traumatic brain injuries. So CENTER-TBI is a very important study that I track for you and professor Andelic is involved in it. 

Introduction to Nada Andelic

[00:45 Melanie] Hi guys, yeah, my voice is weird. This is what’s left of it after a week of covid happiness  and I’ve been waiting for it to clear up, because I really wanted to get this episode to be available to you, and it seems this is what we’ve got to work with.. Luckily, the interview was recorded several weeks ago, so no worries about having to listen to a crackling granny for 20 minutes now. Let me introduce our newest guest: Nada Andelic.

She is a Professor at the University of Oslo, Norway, and a specialist in Physical Medicine and Rehabilitation at the Oslo University Hospital. She is part of the large European research group called CENTER-TBI, which you may remember from previous episodes, and is aiming to improve post traumatic brain injury care. Nada is dedicated to sharing the insights with us, because she believes it’s of vital importance that patients get an understanding of what’s going on with them and how they could get the best rehabilitative care. Let’s listen to Nada Andelic.

Concussion Stories

Welcome to Concussion Stories, a Lifeyana podcast series filled with hope. I’m here to let you know that you are not alone in your concussion recovery. I’m Melanie and I spent more than six years experimenting, training and learning in order to heal myself from a very bad case of post-concussion syndrome. And today, I feel better than ever before.

In Concussion Stories, we dig deep while discussing hopeful stories of recovery as well as the hard stuff in the messy middle. If you’re struggling to focus, be sure to take breaks. Down in the description of each episode, you can find a table of contents in case you want to skip ahead. Let’s dive right in.

Nada Andelic joins the podcast

[01:49 Melanie] Hello. 

[01:50 Nada] Hi, Melanie.

[01:51 Melanie] How are you doing aside from your cold?

[01:54 Nada] I’m quite busy at work. I’m trying to manage that.

[01:59 Melanie] And still you found time to do this with me.

[02:03 Nada] I think it is very important to talk about our work and rehabilitation after traumatic brain injuries with patient organizations such as yours.

[02:13 Melanie] Why do you think it’s so important? 

[02:15 Nada] Because patients could get better help and better care.

Nada Andelic

Nada Andelic

[02:23 Melanie] Before we go any further, I would like to ask you a question, just a little bit about yourself so that the listeners learn a bit more about you. What is something that you normally like to do aside from work? And who do you like to spend your time with?

[02:38 Nada] Thank you for inviting me, Melanie. It is a pleasure to be here. I live in Norway and one of the great things to do here is enjoying nature and outdoor activities such as walking, training and spending time with friends. 

What I also love and enjoy, is going to museums, attending classical concerts, and I am an avid reader. My husband and I like to travel and our daughter works in New York: we are often visiting her. My family members are the most important people in my life – I love quality time with them. 

[03:22 Melanie] It sounds like you’re living a full life.

[03:26 Nada] Yeah. And I’m working as well. 

[03:28 Melanie] Do you love your work? 

[03:30 Nada] Yeah, absolutely. 

Researching mild traumatic brain injury

I have treated many people who sustained traumatic brain injury. And while doing this, I saw that those with milder injuries can have more symptoms, impairments and limitations in daily life and slower recovery compared to those with severe injuries. This can seem a bit counter intuitive and not so obvious to other people. This motivated me to start research on the consequences of TBI and rehabilitation after TBI. And I’ve been doing that since 2005.

[04:08 Melanie] So you became interested in the mild traumatic brain injury field because you were seeing a lot of people who were experiencing a lot of symptoms, even though we weren’t expecting that back in that time. Right? 

[04:25 Nada] Yeah. 

Mild TBI is not so mild

[04:26 Melanie] Now that idea is changing about mild traumatic brain injury as Andrew Maas, also part of CENTER-TBI, already described – that mild TBI is in fact not so mild. 

[04:38 Nada] Yes. 

[04:39 Melanie] This is something that you have found in practice. 

[04:42 Nada] Yeah. And absolutely, this is a very important finding of CENTER-TBI. We recognized that quite a high number of people with mild TBI had persistent symptoms during the first year after the injury, and even many years after the injury. We found that we should further develop mild TBI aftercare, such as follow-up and rehabilitation programs. 

Integrated care for post-concussion syndrome

Integrated care for post-concussion syndrome

You have talked with Maas and Wilson and they shared about measurable changes in the brain such as microscopic injury to the neurons. While this is important, I think it is even more important to consider the whole person. I talk about patient-centered care which promotes health by taking a holistic approach to care, considering the mind, body and spirit of the patient.

[05:42 Melanie] Wow, this is fresh. This is new. This sounds wonderful. Can you elaborate a bit more on how you see that?

What holistic care looks like

[05:49 Nada] This could be achieved through delivering a combination of physical, cognitive, emotional and social services while respecting the patient’s treatment choices because the patient is in the center of the care. There is knowledge-based evidence that such multidisciplinary rehabilitation may reduce persistent symptoms after mild TBI.

[06:17 Melanie] And in Oslo, you’re already practicing this multidisciplinary care approach. 

[06:20 Nada] Yeah, we are doing that.

[06:22 Melanie] Yes, thank you for illuminating the subject… or even that vision that you have and that you’ve already had a chance to put into practice. That will be an amazing example for other countries as well. 

Post-concussion outcomes in men and women

Post-concussion outcomes in men and women

I have a question about several publications that you were involved in last year, actually. The first one is focused on differences between men and women when it comes to traumatic brain injury and specifically concussion, so mild traumatic brain injury. 

If I’m not mistaken, you and your colleagues have uncovered that there is not only a difference between males and females when it comes to how we sustain concussions, but also how it affects us. Is that correct?

[07:04 Nada] Yes, it is. 

Women are more likely to be discharged home

We analyzed the association between men and women In CENTER-TBI, and the outcomes following mild, moderate and severe TBI. We found that following mild TBI, women were less likely to be referred from a hospital to a study center and to be admitted to the intensive care unit. They were also more likely to be discharged home, which is usually related to women’s less severe injuries, different injury mechanisms and better recovery. 

[07:47 Melanie] Okay. 

Women report more PCS symptoms

[07:48 Nada] However, we found that women younger than 45 years and older than 65 years reported worse six months outcomes after mild TBI compared with men of the same age. And in general, we know that women tend to report more symptoms and seek medical help, often. 

We found that symptoms of depression and anxiety are higher for women, especially young women. We know that some hormonal differences may exist in women and men, but we also need to acknowledge the different challenges that the genders experience.

[08:35 Melanie] What kind of challenges do you think about if you say that?

Gender norms and women’s concussion effects

[08:38 Nada] For example, younger women may struggle with the expectation of managing the household and balancing domestic duties and child care with rehabilitation when recovering from mild TBI. 

In addition, a substantial number of young women combine the role of the primary caregiver of children with being a working spouse and parent. In this way, gender norms can create an extra burden for younger women and negatively influence their mental health and quality of life.

[09:17 Melanie] Yeah, this sounds like such a complex puzzle to determine what is happening and how you can service or help or treat everyone the way each and every one of us deserves.

[09:30 Nada] Yes, of course. 

Post-concussion care needs to take women’s health seriously

I would like to highlight that it is important – it is actually critical – that healthcare professionals take women’s health issues seriously and develop appropriate follow-up and treatment programs for the injured.

[09:46 Melanie] Thank you for explaining that, especially all the factors that lay behind it, because it’s something that to be honest, I’ve never looked at the way I was treated, good and bad, by male doctors with regard to my concussion from a gender perspective, but it’s something that I will think about. 

Return to work with or after a concussion

Return to work with or after a concussion

There’s another research paper that you and your colleagues have published. It’s about workplace factors associated with returning to work after a mild traumatic brain injury

And this is such an important topic for a lot of our listeners, because I know a lot of us are struggling with getting back to work or to university or just studies in general. We try to resume our jobs or our function in society (as it may feel to many of us). You have researched this with your colleagues and I was wondering what you could share about this and what can maybe help our listeners? 

Cognitive and vocational intervention

[10:43 Nada] Yes, we conducted a clinical trial in Oslo to evaluate the effects of combined cognitive and vocational intervention on work-related outcomes and health-related quality of life after mild and moderate TBI. 

We used the manualized cognitive compensatory training and support from employment specialists, who support the participants in returning to work. We compared this intervention with a multidisciplinary follow-up that we have at our outpatient’s department. 

The study included patients of working age with persistent symptoms at 8 to 12 weeks after injury. We noted that a significantly larger proportion of patients who receive combined cognitive and vocational intervention had returned to stable employment at three months follow-up. We also noted a difference in the median number of days until reaching preinjury level of employment in favor of the intervention group. 

Cost analysis including informal care by loved ones

We also performed a cost-effectiveness analysis and found that the combined cognitive and vocational intervention was cost-effective when considering the societal perspective, which is productivity loss and informal care – care given by family and friends.

[12:27 Melanie] Yeah, because those burdens are immense, right? 

[12:30 Nada] Yeah. But we did not find a cost effect from a healthcare perspective. So then we looked at our data and we found that health-related quality of life had decreased in the intervention group at the baseline when we started the intervention. This could indicate a greater need for healthcare services in the intervention group, and might have contributed to the higher consumption of healthcare services. 

Better quality of life 12 months after injury

However, we found that the intervention was beneficial to health-related quality of life changes over 12 months. So the intervention group had a better quality of life at 12 months follow-up. That is why we concluded that the study findings gave support to the notion that targeted early intervention programs for patients with mild TBI might be more clinical and cost effective.

[13:37 Melanie] Okay. Aside from the cost effectiveness, which is, of course, very important to bring to policymakers and to insurance companies in order to make a change happen in concussion care, I’m happy to learn that these interventions resulted in the patients having a higher quality of life. 

Tele-rehabilitation for post-concussion care

Tele-rehabilitation for post-concussion care

What kind of interventions should we think about? Because a lot of people don’t have the Norwegian medical system or even medical care at their disposal, if they, for example, have to pay for it themselves in other countries. How could this be shaped by themselves?

[14:15 Nada] We could probably develop tele-rehabilitation interventions that patients could have access to. I can see that you are providing a course like this and this is very important. Tele-rehabilitation should probably be about coping with persistent symptoms, about cognitive compensatory techniques, about returning to work and how you could adjust to the workplace, and so on. 

We know from the COVID time that tele-rehabilitation was very important, and why should we not further develop such a kind of rehabilitation that could be used in post-COVID time as well?

[15:02 Melanie] That’s something that a lot of us learned – right – from that time, that information becomes so much more accessible to all of us if we use technology. 

[15:11 Nada] Yeah. 

An offline possibility to post-concussion tele-rehabilitation

[15:12 Melanie] Even though, for example, my course is also downloadable so that people don’t have to spend all that time on their computers. That’s because a lot of people with concussions have trouble focusing on screens. 

If concussion care becomes more online, it’s so important to ensure that the materials are for example printable or downloadable as an .mp3 file, so that people can listen to it on their phones and don’t have to watch their screens all the time.

[15:40 Nada] Yes, absolutely. It is very important, in combination with active recovery.

Post-concussion care: psychological work

Post-concussion care: psychological work

[15:45 Melanie] You mention active recovery. It relates a bit to a question that I’d like to ask you. Is there something that really surprised you during all of this time treating patients, researching traumatic brain injury, that you discovered?

Emotional distress from persistent concussion symptoms

[15:59 Nada] Yes, absolutely. There are a lot of symptoms patients are dealing with, not only symptoms related to concussions, but also problems when it comes to accepting that. Acceptance of the symptoms and emotional distress is very important in concussions. 

So we should treat persistent symptoms with a multidisciplinary rehabilitation team and teach patients how to cope with the challenges after concussions. 

My psychological recovery from PCS

[16:36 Melanie] Yes, I think that if I look back, the psychological work that I needed and eventually wanted to do in order to heal was, I think, more than 50% of the work. Because even if you do all of the training, like brain training and physical training, and all of the relearning that you need to do… the psychological part plays a big part in that as well. 

For example, if you are having trouble with your training because you’re having a setback, you need your mental resilience in order to get back to work again, and give it another try and do it better this time. That’s such a big part of recovery.

[17:19 Nada] Yeah, absolutely. I agree with you.

Holistic care is the future for PCS 

Holistic care is the future for PCS 

[17:22 Melanie] I think it’s wonderful what you’re doing. And I really admire that you have this perspective that indeed the patient should be centered and you need a holistic approach. That vision is so different from everything that I experienced and I am really, really glad to hear that lessons are being learned. That’s the most important part. 

[17:44 Nada] Yeah, that’s the most important thing. I agree with you.

Thanking Nada

[17:48 Melanie] You manifest those lessons into realities. I hope that you may be an example for other practitioners and for other researchers. Thank you so much for sharing your insights and your vision with us.

[18:02 Nada] Thank you, Melanie.

Let me know what YOU think?

[18:05 Melanie] Now, I would love to hear from you. What do you take away from this episode? Is there something that you can apply to your life right away? Head on over to lifeyana.com and leave your comment now.

If you want to hear and read more Concussion Stories, actionable steps and inspiration, be sure to subscribe to the Lifeyana email list while you’re there, so that you never miss out on new materials we constantly make for you.

If you want to support this podcast, head on over to patreon.com/confessionstories. Thank you for listening to this Concussions Stories episode by Lifeyana. May you be well and may you be happy.

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