Understanding Concussion
Assessment and Evaluation
Philip Schatz, PhD
Saint Joseph’s University, Philadelphia PA
pschatz@sju.edu
Cerebral Concussion
• Mild traumatic brain injury
• Alteration in consciousness due to a blow to the
head or acceleration/deceleration/rotational
force
• Does NOT imply or require loss of
consciousness.
• Usually temporary changes in mental status
• Temporary changes in somatic functioning
• May produce a wide range of symptoms
• Normal structural neuroimaging
CISG, Vienna (2001); Prague (2004)
Post Concussion Symptoms
“Oh man… I was licking the dreamsicle”
-- Professional wrestler, reflecting on a concussion
Head Games
Chris Nowinski
Post Concussion Symptoms
“Physical”:
• Pressure in head
• Headache
• Balance troubles
• Visual Disturbance
• Numbness
• Tingling
• Feeling slow
• Sensitivity to
light/noise
“Psychological”:
• Feeling like in a “fog”
• Difficulty concentrating
• Difficulty remembering
• Irritability
• Sadness
• Nervousness
COMMONLY REPORTED SYMPTOMS
High School/University Athletes within 3 days of injury










Headache (71%)
Feeling slowed down (58%)
Difficulty concentrating (57%)
Dizziness (55%)
“Fogginess” (53%)
Fatigue (50%)
Visual Blurring or double vision (49%)
Light sensitivity (47%)
Memory dysfunction (43%)
Balance problems (43%)
Physiological Changes
• Shearing or strain injury of axons
• Diffuse microscopic changes to
axons
• Microscopic tearing of small blood
vessels
• Metabolic cascade resulting in
imbalance between glucose
demands and regional CBF supply
(vulnerable to SIS)
Giza & Hovda, JAT, 36(3), 228-35
Neurometabolic Changes
Incidence of Mild TBI
 75 to 85 % of all head injuries
 1.0 to 1.5 million cases per year in US
 300,000 from sports (an underestimate?)
 Most cases go unreported
Incidence of Mild TBI
 Question: What sport has the
highest incidence of concussion (if
you know, don’t say it)
Previous Findings: Epidemiology
• By Sport:
SPORT
Equestrian
Boxing
Rugby
Soccer
Football
Bicycling
Martial Arts
Auto Racing
Ice Hockey
% RANGE
3 - 91
1 - 70
2 - 25
4 - 22
2 - 20
0 - 13.8
0 - 11
0 - 10.5
3 - 7.5
Ruchinskas, et al., 1997, Applied Neuropsych
Epidemiology: Issues (Macciocchi)
– Recognition one occurred may be easier then
measuring concussion severity
– Diagnosis for epidemiological purposes may be
more difficult than it seems
• Discrepancy between # of players reporting and the #
who believed they sustained one
• Post-season, players reported symptoms but didn’t
connect them to concussive injuries
• 70% of football and 63% of soccer players reported postconcussion symptoms
Epidemiology: Methods (Macciocchi)
– Quasi-experimental comparison- athletes
examined pre-season, followed for a period
of time
• Look at # of concussions sustained over that period
• Generalize from cohort to population
– Use date from “surveillance systems”
• Monitor concussive injuries on a broader scale
• Sometimes are organization-based, such as NCAA
Epidemiology: Terminology
(Macciocchi)
– Athletic Exposure (AE)
• Period of time when an athlete could have sustained an
injury, such as practice or game
• Confounded by time (a 5-minutes shift is the same as an
entire game)
– Injury Rate (IR)
• Number of injuries incurred relative to the total number of
exposures
• Often stated as “per 1000 AE’s”
Epidemiology: High School
– 20% or 250,000 per year in football (Gerberich,
et al. 1985)
– 25,520 per season (Powell, 1995)
– NATA High School Study
–
–
–
–
–
–
57,716 occurrences of mTBI per year
5.3% of football injuries
4.4% of wrestling injuries
3.4% of boys soccer
2.6% girls soccer
2.3% girls basketball
Epidemiology: NCAA
• College: NCAA Injury Surveillance
System
–
–
–
–
–
–
–
1.6 to 6.4% of all injuries
Ice Hockey - 4.5% of all injuries (.56 per 1,000 AE)
Football .43 per 1,000 AE
Wrestling .49 per 1,000 AE
Soccer (Men = .35/Women=.58)
Lacrosse (Men= .33/Women=.62)
Basketball (Men=.16.Women=.29)
Concussion Base Rates
• History of Previous Concussion: 10-80%
• Recent Trend Upwards:
(% with 1+ Previous Concussion)
– Collins, et al (1999) 53%
– Kaushik (2005) 75%
– Moser, Schatz, Jordan (2005) 63%
• Different “breed” of youth athletes in 2000’s vs.
1980’s?
What about Gender?
Hillary, Mann, Schatz, ACN, 2002
Study
Powell, Barber-Foss
Powell, Barber-Foss
Powell, Barber-Foss
NCAA
Study
Dick
Dick
Boden, et al.
NCAA
Powell, Barber-Foss
Powell, Barber-Foss
Powell, Barber-Foss
J. Kelly, J. Rosenberg
Sport (% of All Injuries)
Soccer
Basketball
Baseball/Softball
Soccer
Males
3.9%
2.6%
1.7%
4.7%
Females
4.3%
3.6%
2.7%
4.4%
Total % of all injuries
3.23%
3.75%
Sport (Injuries per 1000 AE)
Soccer
Lacrosse
Soccer
Soccer
Soccer
Basketball
Baseball/Softball
Soccer
Males
0.348
0.334
0.6
0.44
0.18
0.11
0.05
0.25
Females
0.578
0.618
0.4
0.46
0.23
0.16
0.1
0.24
Total Ave per 1000 AE
Soccer Ave per 1000 AE
Other Ave per 1000 AE
0.289
0.364
0.165
0.348
0.382
0.293
Epidemiology: Gender
Covassin, Swanik, Sachs, JAT, 2003)
NCAA Injury Surveillance System: 3-year study
• Of 14,591 reported injuries, 5.9% were classified
as concussions
Concussions during practices:
Female athletes:
Male athletes
167 (3.6%)
148 (5.2%)
Concussions during games:
Female athletes:
Male athletes:
304 (9.5%)
254 (6.4%)
Epidemiology: Gender
Covassin, Swanik, Sachs, JAT, 2003)
Barnes, et al, 1998, Am J Sports Med:
• Female athletes could be at more risk due to their
smaller size or greater ball-to-head size ratio.
• Female athletes may have weaker neck muscles than
male athletes.
Boden et al, 1998, Am J Sports Med:
• Male athletes may be more skilled at protecting their
heads from injury, but there are no data to support this
hypothesis.
Gender Differences at Baseline
1209 NCAA Division 1 Athletes - 5 Northeastern Universities
• Completed ImPACT at baseline
• Female athletes performed significantly better than male
athletes on baseline verbal memory scores (p = 0.001)
• Male athletes performed significantly better than female
athletes on baseline visual memory scores (p = 0.001).
Covassin, Swanik, Sachs, Kendrick, Schatz, Zillmer,
Kaminaris, (BJSM, 2007)
Gender Differences at Baseline
Female athletes endorsed a significant number of mild
baseline symptoms as compared to male athletes:
• Headache, nausea, fatigue, need more sleep,
drowsiness, sensitive to noise, sadness, nervousness,
more emotional, difficulty concentrating, visual problems.
• Effect sizes ranged from .13 (Sleep) to .40 (Emotional)
Covassin, Swanik, Sachs, Kendrick, Schatz, Zillmer,
Kaminaris, (BJSM, 2007)
Recommended schedule for
measuring post-concussion status
NP
Sideline
RETURN TO
Testing Testing
PLAY?
BASELINE
NP
TESTING
INJURY
PRE-SEASON
1-2 DAYS AFTER
INJURY
Historical Aspects:
UVA Football Study - Barth, et al., 1989
Trail Making B: Pre-Season and Post-Injury Performances
Historical Aspects:
Neuropsych Measures-Trails B
Historical Aspects:
Neuropsych Measures-Digit Symbol
Historical Aspects:
Neuropsych Measures - PASAT
Historical Aspects:
Neuropsych Measures - COWAT
Tell me as many words that you can think of
that start with the letter… F…A…S.
Historical Aspects:
Neuropsych Measures - STROOP
Historical Aspects:
Neuropsych Measures - STROOP
Historical Aspects:
Neuropsych Measures - STROOP
Historical Aspects:
Neuropsych Measures - STROOP
Historical Aspects:
UVA Football Study - Barth, et al., 1989
PASAT-4: Pre-Season and Post-Injury Performances
Historical Aspects:
Echemendia PSU: Hockey: COWAT
% Relative to Baseline
20
0
Baseline
2 Hour
48 Hour
1 Week
-20
-40
-60
Concussed
Control
1 Month
Historical Aspects:
• Egocentric view:
– The Virginia Football Study
– Echemendia’s PSU Program
– Saint Joseph’s University
• Division I, No Football, 400+ varsity athletes
– Where can I find a place?
– Computers circa 1998
What We Knew: 2000
• Effects of Cerebral Concussions last up to 7-10 days
– Primarily attention and concentration
Alves, Rimel, Nelson, 1987, Clinical Sports Medicine, 6(1),
211-8
Barth, et al., 1989, in H. Levin’s Mild Head Injury: Oxford
Press
• Effects of cerebral concussions last up to 30 days
and beyond (Echemendia, et al., 1999)
– Extends to other cognitive processes
Echemendia & Julian, 2001, NP Review 11(2), 69-88
What We Knew: 2000
• LOC is not a predictor of concussion,
and incidence of LOC does not effect
cognitive performance
(Lovell, et al, J. Clin Sports Med, 1999)
• Individuals with history of Concussion
and/or Learning Disability show lowered
baseline performance on testing.
(Collins, et al., JAMA, 1999)
Current Research: How do I develop
a Concussion Program at SJU?
(Hopefully) based on Professional and Collegiate
Concussion Management Programs
•
•
•
•
•
NFL - Majority
NHL - Mandatory
Baseline, Serial Post-concussion Evals.
Wide Network of Neuropsychologists
Colleges test teams pre-season
SJU Concussion Pilot Study: Trails B
SJU Concussion Pilot : Digit-Symbol
SJU Concussion Pilot Study: d2
There already was a trend towards
computer-based assessment
• CRI (HeadMinder.com)…………. 1999
– Web based
• CogSport (CogState.com)………..1999
– Windows/Mac
• ImPACT (ImPACTtest.com)……. 2000
– Windows based
Why should we opt for
computer-based assessment?
• Sensitive to RT, Processing Speed
• Randomized Trials: Improved reliability
• Ability to test entire team at once
(benefit?)
• Better/Objective date for Athletic Trainers,
Team Physicians
• Assistance with Return to play decisions
(Schatz & Zillmer, 2003, Applied Neuropsych; Schatz & Browndyke, 2003, JHTR)
Why should we not opt for
computer-based assessment?
• Perhaps timing is not millisecondaccurate
• Limited validation with np “standards”
• Little qualitative or “verbal” data
• Can be used by Athletic Trainers, Team
Physicians in absence of Neuropsych
• May determine return to play decisions
(Schatz & Zillmer, 2003, Applied Neuropsych)
There’s a whole lot of post-concussion
tests and schedules
Comparison of Post-concussion Assessment Schedules and Measures. (From McKeever & Schatz, Applied Neuropsychology, 10, 2003)
Study
NCAA- Multiple sports
(Echmendia, et al., 2001)
NCAA-Football
(Collins, et al., 1999)
Schedule of Serial Post-Concussion Assessments
Hours Days
1-2
24-48
3
5
7
10
30
2
24
7
30
1
3
5
24
5
Prof. Hockey Players
(Echemendia, 2001)
24
5b
Prof. Football Players
(Lovell & Collins, 1998)
24
Prof. Rugby Players
(Hinton-Bayre, et al., 1999)
aAthletes
dHVLT, hTrails, kDig.
7
Span, fSDMT, mCOWAT,
nPegboard
NCAA-Football
(Barth, et al., 1989)
Prof. Rugby Players
(McCrory, et al., 1997)
Measures Used
cPC, dHVLT, fSDMT, gStroop, hTrails, jVIGIL/W,
kDig. Span, lPSU,mCOWAT
eSDMT, hTrails, oPASAT
10
7b
cPC, dHVLT, fSDMT, iTrails, lPSU, mCOWAT,
pBVMT-R
dHVLT, fSDMT, hTrails, kDig.
5
Span, mCOWAT,
nPegboard
1
eSDMT, rChoice
5
3a
7a
35 a
eSDMT, qDigit
RT., rMemory, rOrientation
Symbol, rSpeed of Comprehension
tested 1 to 3 days, 1-2weeks, 3-5 weeks post-concussion; bAthletes tested 5 to 7 days post-concussion
Power In Numbers:
Philadelphia Sports Concussion Program
•
•
•
•
•
Mandatory for Participation in Athletics
Drexel, Temple, SJU… Delaware, Rutgers
Baseline, 24-48 hr, 3, 5, 7, 10, weekly if Sx
ImPACT @ 4 schools, CRI @ Temple
Dissertations (McKeever, Covassin,
Schneider), Master’s Theses
– Validate multiple measures
(ImPACT, CRI, CogSport, Trails, Digit Symbol, d2)
– Gender, Sport, History, Club Sports, Cheerleaders, School Norms
Cross-Validation of Computer-Based
Measures - Rationale
(Schatz & Putz, Applied Neuropsych 2006)
• Limited “shared validation” of existing
computer-based measures with standards
• SDMT correlates with:
– ImPACT Processing Speed (r=.70) and Reaction Time (r=.60)
– CRI Processing Speed (r=.60, r=.67)
• Trails correlates with:
–
–
–
–
CRI Response Speed (A: r=.73; B: r=.74)
CRI Processing Speed (B: r=.37)
CogSport Complex RT (B: r=.34)
CogSport Simple RT (B: r=.44)
Cross-Validation of Computer-Based
Measures - Methodology
• 30 Normal Volunteers
• Computer-based: ImPACT, CRI,
CogSport, d2, Trails A&B, Digit Symbol
• Paper-based: Trails A&B, Digit Symbol
• Administration: MWF, Individually
– Grouping A: ImPACT, d2 Test of Attention (computerized)
– Grouping B: CRI, Trails A and B. and Digit Symbol (pencil and
paper).
– Grouping C: CogSport, Trails A and B, and Digit Symbol
(computerized).
– ABC, ACB, BAC BCA, CAB, CBA.
Cross-Validation
Example: ImPACT CRT
Cross-Validation
Example: CogSport CRT
Cross-Validation
Example: CRI CRT
Cued Reaction Time:
Press the spacebar as quickly as possible only when a
white circle immediately follows the presentation of a
black square.
Cross-Validation of Computer-Based
Measures - SRT Results
IMPACT
IMP ACT
SRT
--.
HD_CRT
COG_CRT
.598*
.001
.407*
.026
.649**
.001
.380**
.038
.641**
.001
.442*
.014
DIGSYM
-.455*
.012
---
.404*
.027
.391*
.032
.292
.118
.428*
.018
.232
.217
-.526**
.003
---
.333
.072
.421*
.021
.055
.772
.315
.091
-.303
.104
---
.420*
.021
.544**
.002
.535**
.002
-.281
.132
.277
.138
.172
.362
-.076
.689
.613**
.001
-.373*
.042
HD_SRT
HD_SRT
.
HD_CRT
COG_CRT
COG_SRT
TRA
TRB
COG_SRT
---
TRA
---
TRB
---
-.381*
.038
Cross-Validation of Computer-Based
Measures - CRT Results
IMPACT
IMP ACT
SRT
--.
HD_CRT
COG_CRT
.598*
.001
.407*
.026
.649**
.001
.380**
.038
.641**
.001
.442*
.014
DIGSYM
-.455*
.012
---
.404*
.027
.391*
.032
.292
.118
.428*
.018
.232
.217
-.526**
.003
---
.333
.072
.421*
.021
.055
.772
.315
.091
-.303
.104
---
.420*
.021
.544**
.002
.535**
.002
-.281
.132
.277
.138
.172
.362
-.076
.689
.613**
.001
-.373*
.042
HD_SRT
HD_SRT
.
HD_CRT
COG_CRT
COG_SRT
TRA
TRB
COG_SRT
---
TRA
---
TRB
---
-.381*
.038
Cross-Validation of Computer-Based
Measures - Processing Speed Results
Digit Symbol
Trails B
-.381*
Digit Symbol
-
ImPACT
-
p < . 05*, p < .004**, p < .001***
ImPACT
HeadMinder
-.506**
.601***
.542**
-.610***
-
-.373*
Cross-Validation of Computer-Based
Measures - Memory Results
ImPACT Visual
ImPACT Verbal
.340
CogSport Visual
-.160
-.102
-.058
ImPACT Visual
-
-.012
CogSport Visual
-
-
p < .05*
CogSport Learning
.723*
Cross-Validation of Computer-Based
Measures - Implications
• These tests share some common variance on
constructs such as processing speed and reaction
time, but not within the domain of memory.
• The Processing Speed Indices/measures (ImPACT,
HeadMinder, Trails B and Digit Symbol) correlated
the most consistently.
• Baseline evaluations using one measure can not be
used as a basis for post-concussion assessment
using another measure.
Cross-Validation of Computer-Based
Measures - Limitations
• Small sample size.
• Reliance on univariate correlations.
• Subjects assessed independently.
• No concussed subjects.
• Not comparing tests’ sensitivity to effects of
concussion.
Meanwhile…
Concussion Effects on Youth
Athletes?
 Relying on symptoms
alone may be
dangerous
 Attentional processes,
memory, and cognitive
speed are key elements
of testing
 Younger athletes
deserve particular
attention
Prolonged Effects of Concussion?
(Schatz & McNamara ACN 2001 [Abstract])
• Self-reported history of concussion
• 56 college freshmen, ages 17-19
• Divided into independent groups on the
basis of concussion history:
– 19 with one or more previous concussion,
– 39 with self-reported history of no previous
concussions.
Prolonged Effects of Concussion?
(Schatz & McNamara ACN 2001 [Abstract])
Mild, enduring effects of cerebral concussion can be identified in
otherwise healthy college freshmen with a history of concussion.These
enduring effects of previous cerebral concussions appear to involve
attentional processes, and warrant further investigation.
Prolonged Effects of Concussion?
(Moser & Schatz ACN 2001; Moser, Schatz, Jordan, Neurosurgery 2005)
• Youth Athletes from a college-prep
boarding school (Ivy-bound)
• Mandatory participation in sports
• Multiple sports over 5-10 years
• No concussion program in place
• Attempt to understand/replicate
Dependent Measure: RBANS
Subtests measure multiple neurocognitive domains
•
Immediate Memory
•
Visuospatial/Contructional
List Memory - recall of 10 words presented orally.
Story Memory - recall of short story presented orally.
Figure Copy - Copy of multi-part geometric drawing.
Line Orientation - identify lines from a drawing.
•
Language
Picture Naming - Naming of pictures of objects.
Semantic Fluency - Name examples from category in one minute.
•
Attention
Digit Span - Repeat a string of digits presented orally.
Coding - Matches geometric shapes corresponding to numbers.
•
Delayed Memory
List Recall - Recall 10 words learned in the List Learning subtest.
List Recognition - recognition of 20 words presented orally.
Story Memory - Recall of short story learned earlier.
Figure Recall - Draw, from memory, the figure shown earlier.
Prolonged Effects: Pilot Study
(Moser & Schatz, Arch Clinical Neuropsych 2001)
Youth athlete volunteers, divided into independent groups
on the basis of concussion history.
• Zero or One Previous Concussion: 8 healthy volunteers with either no
history of concussion, or had sustained one previous concussion
(not within the past six months).
• Two+ Previous Concussions: 13 youth athletes who had sustained two
or more previous concussions (not within the past six months).
• Recent Concussion: 13 youth athletes who had sustained a recent
concussion, with no identified medical or neuropsychological difficulties
related to concussion one week after testing.
Prolonged Effects: Pilot Results
RBANS Mean Raw Scores
Concussion Group
n
Total
Coding
Attention
_____________________________________________________________
0-1 Previous
8 Mean
252.63
63.88
77.38
Concussion
SD
14.10
7.18
9.59
_____________________________________________________________
2 or More Previous
13 Mean 240.54
55.92
68.69
Concussions
SD
14.85
6.68
8.10
_____________________________________________________________
Rece nt
13 Mean 233.77
53.15
65.38
Concussion
SD
15.92
10.71
9.20
_____________________________________________________________
RBANS Coding: [F(2,31)=3.98; p = .029; r = .50]
RBANS Attn:
[F(2,32)=4.59; p = .018; r = .55]
Note: High er Mean Scores = Stronger Cognitive Functioning.
Analyses are two-tailed; Effect sizes denoted by "r".
Follow-up Study
(Moser, Schatz & Jordan, Neurosurgery 2005)
238 youth athlete volunteers ... divided into four independent
groups on the basis of concussion history.
• No Concussion: 82 healthy volunteers with no history of concussion.
• One Previous Concussion: 56 youth athletes who had sustained one
previous concussion (not within the past six months).
• Two+ Previous Concussions: 51 youth athletes who had sustained two
or more previous concussions (not within the past six months).
• Recent Concussion: 49 youth athletes who had sustained a recent
concussion, with no identified medical or neuropsychological difficulties
related to concussion within one week of testing.
Prolonged Effects-GPA
GPA by Concus s ion Gr oup
3.55
3.5
3.45
3.4
3.35
3.3
3.25
3.2
3.15
3.1
3.05
No Concussion: (82)
One Previous: (56)
Two+ Pr evious: ( 51)
Concussion Group
Recent: (49)
Prolonged Effects-RBANS
RBANS Subte st by Concus s ion Gr oup
80
No Concussion: (82)
One Previous: (56)
70
Two+ Pr evious: ( 51)
Recent: (49)
60
50
40
30
20
10
0
*Attn
IMM
DEM
RBANS Subtest
Lang
VisC
Prolonged Effects: Results
• Multivariate Analysis of Variance (MANOVA)
revealed a significant overall effect of
concussion history on cognition
[F(21,672)=1.8; p=.015].
• Univariate F-tests revealed significant main
effects of concussion history on Attention
[F(3,228)=4.72; p=.003] and GPA [F(3,228
=5.76; p=.001].
Prolonged Effects in Youth
Athletes
• Health non-concussed youth athletes with a
history of concussion often show subtle deficits in
attention and concentration at baseline
assessment.
• These enduring effects of previous cerebral
concussions can be detected using traditional
measures.
• Concussions appear to occur in female athletes at
a greater rate/frequency.
Youth Athletes: What we think we
know:
Contributing to these findings:
•A more vulnerable and susceptible youth brain
•Participation in multiple sports over a long
period of years.
Emotionality
• Feeling more emotional
• Sadness
• Nervousness
• Irritability
Somatic Symptoms
Cognitive Symptoms
• Attention Problems
• Visual Problems
• Dizziness
• Balance Difficulties
• Headaches
• Light Sensitivity
• Nausea
• Memory dysfunction
• “Fogginess”
• Fatigue
• Cognitive slowing
Sleep Disturbance
•Difficulty falling asleep
• Sleeping less than usual
Factor Analysis, Post-Concussion Symptom Scale
N=327, High School,Univ Athletes Within 7 Days of Concussion (Pardini et al, 2004)
Post-Concussion
Gender Differences
Covassin, Schatz, Swanik, Neurosurgery, 2007)
79 NCAA Division 1 Athletes
• Completed ImPACT at baseline
• Sustained concussion warranting serial assessment up
to 10 days post-concussion
• Average 3, 8 days post-concussion
• Males (N=41): Baseball, cheerleading, football, ice
hockey, lacrosse, soccer, volleyball, and wrestling
• Females (N=38): basketball, cheerleading, gymnastics,
lacrosse, soccer, softball, volleyball,
Post-Concussion Gender
Differences
Covassin, Schatz, Swanik, Neurosurgery, 2007)
Baseline: No Gender differences [F(5,73)=.80; P=0.55]
Post-Concussion: 3x2 mixed-factoral design MANOVA
• Time (Baseline, 3 days, 8 days):
[F(2,76)=1670; P=0.0001; ES=.98]
• Gender:
[F(1, 77)=.16; p=.69; ES=.002]
•Time x Gender Interaction: ]F(2,76)=.54; p=.59, ES=.01]
Post-Concussion Gender
Differences
Covassin, Schatz, Swanik, Neurosurgery, 2007)
Post-Concussion Symptoms:
Male athletes reported significantly higher symptom scores
for:
• Sadness [F(1,77)=13.05, P=0.001]
• Vomiting [F(1,77)= 5.95, P=0.017]
Post-Concussion
Gender Differences
Covassin, Schatz, Swanik, Neurosurgery, 2007)
Reliable Change Indices (RCI):
At Time 1 (up to 3 days post-injury):
• 58% of participants had one or more reliable
declines in performance or increases in symptom
reporting
At Time 2 (up to 10 days post-injury):
• 30% of participants were still showing one or more
reliable changes from pre-season levels.
NEW MANAGEMENT STRATEGIES
CIS Group, Vienna (2001), Prague (2004)
Removal of symptomatic athletes from play
Graduated return to play
Neuropsychological testing recommended
“One of the Cornerstones of Management”
Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell,
McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.
Current Large-Scale Programs
Neuropsychological Testing
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20 NFL Teams
IRL, F1, CHAMP Car
NASCAR
USA Olympic Hockey
USA Hockey
400 + High Schools in US
60 Sports Medicine Clinics
in US
 Pro Boxing in California
 USA Ski Team
 USA Soccer Juniors
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Ontario Hockey League
New Zealand Rugby
S. African Rugby
World Cup Soccer
150 + Universities in US
Many Neuropsychology Clinics
in US
 Major League Baseball
 Major League Baseball
Umpires
WHY USE NEUROPSYCHOLOGICAL TESTING?
Unique Contribution To The Diagnostic Puzzle
Testing Provides Unique Information
Concussed Athletes Often Deny Symptoms
Athletes May Lack Awareness of Symptoms
UNIQUE CONTRIBUTION OF
NEUROPSYCHOLOGICAL TESTING
TO CONCUSSION MANAGEMENT
Symptomatic
Testing reveals
cognitive deficits
in asymptomatic
athletes within 4
days post-injury
Asymptomatic
100
95
90
85
80
75
70
65
60
55
50
Ve rbal
Memory
N=215, MANOVA p<.000000
Visual
Memory
Control
UNIQUE CONTRIBUTION OF
NEUROPSYCHOLOGICAL TESTING
TO CONCUSSION MANAGEMENT
Symptomatic
Asymptomatic
Control
Symptomatic
0.8
50
0.7
45
0.6
Aysmptomatic
Control
40
0.5
35
0.4
0.3
30
0.2
25
Reaction Time
Reaction Time
Processing Speed
Processing Speed
MANOVA p<.000000 (ImPACT Test Battery)
VALUE ADDED OF NEUROPSYCHOLOGICAL
TESTING
NP testing
increases
Diagnostic
yield to
88%
100
95
90
85
80
75
70
65
60
55
50
%declined
From baseline
88
82
EITHER
Either
65
NEUROPSYCH
Neuropsych
Symptoms
SYMPTOMS
% DEC LINED
FRO M BL
201 concussed High School and collegiate athletes tested with 2 days of
injury. Abnormal performance determined by RCI’s (van Kampen, 2004).
WHY USE NEUROPSYCHOLOGICAL TESTING?
Mild or “Ding” Injuries May be Significant
Cannot gauge severity of injury based on initial
symptoms
Acute recovery may not be a linear process
Concussion and Memory Dysfunction
 64 high school athletes with Grade 1 concussion
 24 Non-injured control subjects
 All athletes diagnosed with ”ding”
Confusion, amnesia, signs/symptoms cleared
within 15 minutes
No athlete in sample sustained LOC
 No athlete returned to contest
 ImPACT evaluation obtained at baseline, 36 hours,
4 days and 7 days post-concussion
Lovell et al., J. Neurosurgery, 2003.
Memory Impairment Following
“Mild Concussion”
CONCUSSED
CONTROLS
90
85
80
75
70
Baseline
36 Hours
Day 4
Time of Evaluation
Lovell, Collins, Iverson et al., J. Neurosurgery, 98,
2003
Day 7
Summary
 Current research supports the use of
neuropsychological testing following concussion
 Relying on symptoms alone may be dangerous
 Attentional processes, memory, and cognitive
speed are key elements of testing
 Younger athletes deserve particular attention
And Now for Something Completely
Different…
Effort: (Green, et al., Brain Injury, 2001)
• >50% of variance in scores was due to
poor effort
• Education = 11%
• Age = 4%
Symptom Validity Testing (Bush, et al NAN, ACN),:
“it is necessary to evaluate symptom validity
objectively in any neuropsychological assessment”
And Now for Something Completely
Different…
• Daubert v. Merrell Dow Pharmaceuticals
(1993) held that trial judges should
permit expert scientific testimony only
when “the reasoning or methodology
underlying the testimony is scientifically
valid, and …properly can be applied to
the facts in issue.”
And Now for Something Completely
Different…
Effort Tests:
• Rey 15-item, Dot Counting
• Test of Memory Malingering (TOMM)
• Word Memory Test (WMT)
• CARB (Comp. Assess. Response Bias)
• Validity Indicator Profile (VIP)
• MMPI-2
Assessment of Effort - Rationale
(Schatz & Sucharski, in some stage of submission)
• Little data on effort at time of assessment:
– “…speculation that athletes are often motivated to underreport
symptoms so they can return to competition” (Echemendia & Cantu,
2003)
– “…motivated to underreport subjective symptoms to hasten the
return to competition.” (Erlanger, et al., 2003)
– “An athlete’s apparent fear of removal from a game or of losing his
or her position on the team may tempt some athletes to deny or
underreport postconcussive symptoms.” (Lovell, 1998)
– “Ostensibly, symptom minimization occurs in hopes of a faster
return to the playing field, court or ice.” (Lovell, et al., 2002)
– “it is more likely that suspicion regarding the use of the test results
and/or general disinterest and apathy could impact the accurate
measurement of cognitive ability at baseline” (Echemendia &
Cantu, 2003)
Assessment of Effort - Rationale
• Bailey, Echemendia, Arnett (2006), JINS
– Assigned to High Motivation at Baseline (HMB) and Suspect
Motivation at Baseline (SMB) groups based on whether
baseline performance fell one or more standard deviations
from the mean of the given measure
– N=26 to 33, Pre, Post-Mild TBI, Trails, Dig Span, Stroop
–
In repeated measures ANCOVA (that removed achievement
performance), the SMB groups demonstrated greater
improvement than the HMB groups for the Trail Making Test A
& B ( TMT-A & B), Digit Span, and Stroop-Color Word
(Stroop-CW) tests.
Assessment of Effort - Methodology
• 155 Participants: 77 athletes, 78 from
human subjects pool
• Administered Word Memory Test (WMT)
and ImPACT
• Only looked at Baseline performance
Assessment of Effort - Methodology
Word Memory Test (WMT):
1. Show word pairs (e.g., Boy-Girl)
2. Show “cue” word (e.g., Boy)
3. Show “target” choices (e.g., Girl, Truck)
TBI Patients 95%+
Assessment of Effort - Incidence
• Incidence of Poor Effort
Good (>95%)
Poor (<95%)
Athletes
48 (62.3%)
29 (37.7%)
Non-athletes
43 (55.1%)
35 (44.9%)
[X^2(1, N=155)
=.831; p=.36]
Assessment of Effort - Effects
Good (>95%)
P oor (<95%)
F
Sig. F
SYMP T OM T OT A
L
6.97
(9.642)
10.73
(13.394)
4.148
.043
VERBAL MEMORY
.892
(.081)
.831
(.110)
15.689
.000
VISUAL MEMORY
.767
(.127)
.701
(.126)
10.327
.002
P ROCESS SPEED
42.676
(5.871)
38.128
(7.834)
17.063
.000
REACT IONTIME
.537
(.077)
.562
(.075)
4.120
.044
IMP ULSE CT RL
8.912
(14.238)
10.922
(17.151)
.631
.428
Validation of MilliSecond Accuracy in
MicroComputers (unpublished data)
PhotoCell
Internal Timer
External Timer
Mouse-click=stops both
Compare…
Calculate Difference Score
Validation of MilliSecond Accuracy in
MicroComputers (unpublished data)
Validation of MilliSecond Accuracy in
MicroComputers
Validation of MilliSecond Accuracy in
MicroComputers
Validation of MilliSecond Accuracy in
MicroComputers
Validation of MilliSecond Accuracy in
MicroComputers
Millisecond Accuracy?
Baseline to post-concussion
computers
Caution when interpreting reaction
time and processing speed
 Use of software by clinicians
Assessment of Effort - Implications
• Given the wide-spread use of computer-based
tests for the purpose of documenting baseline
cognitive function in athletes, neuropsychologists and sports-medicine
professionals should utilize external measures
of athletes' effort.
• Further, employing normal controls from
human subjects pools may provide less
accurate comparisons than desired.
What we need to know more
about:
Diagnosing and managing concussions with
computer-based measures:
• Ongoing, external validation of existing measures
• Ongoing validation of computer-based measures
in prospective clinical samples
• Accurate standard for timing accuracy
What we need to know more
about:
Diagnosing and managing concussions in youth
athletes:
• Junior High, Grade School, Youth Leagues
• JV, Club Sports
• Gender
What we NEED:
• Baseline screenings for all athletes, but especially
in vulnerable youth athletes.
-documenting pre-concussion status,
-pre and post concussion comparisons
-multiple “sliding” baseline.
• Public service announcements
• Involvement /awareness of pediatricians and
family practices = Neurop$ychology