Neuropsychological Assessment in Sports-Related Concussion: Part of a Complex Puzzle

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2 Neuropsychological Assessment in Sports-Related Concussion: Part of a Complex Puzzle Jillian Schuh, PhD 1, 2, John Oestreicher, PhD 1, & Linda Steffen, PsyD 1 1 Catalpa Health 2 Department of Neurology, Medical College of Wisconsin Contact information:

3 Objectives Post-Concussion Syndrome Multidimensional model of concussion assessment Neuropsychological assessment What it is When to refer Information gathered and domains assessed Information gleamed and recommendations

4 Acknowledgements Concussion Clinic David Leicht, PhD John Oestreicher, PhD, ABPP-CN Linda Steffen, PsyD Department of Neurology Amy Heffelfinger, PhD, ABPP-CN Michael McCrea, PhD, ABPP-CN

5 Concussion: Integrated Recovery Model Courtesy of Michael McCrea, PhD, ABPP-CN

6 Post-Concussion Syndrome Somatic (headache, fatigue, dizziness, sleep disturbance) Cognitive (inattention, forgetfulness, slowed processing) Affective Symptoms (irritability, disinhibition, lability, anxiety, depression, apathy)

7 Post-Concussion Syndrome: A Biopsychosocial Model 1 Post Injury Factors Neurocognition Mental Health Social Factors Sleep Disturbance Vestibular Injury Chronic Pain Pre Injury Factors Personality Characteristics Resilience Vulnerability Preexisting Mental Health Substance Abuse Prior Brain Injuries Prior Medical/Neurological 1 Adapted from Iverson, 2012

8 Multidimensional Model of Concussion Assessment 1 Comorbid/ Complicating Factors Concussion History Multidimensional Assessment Symptoms Balance/ Postural Stability Cognition Cognitive recovery often FOLLOWS symptom resolution! 2 1 Echemendia, et al, 2013; 2 McCrary, et al., 2013

9 Neuropsychological Assessment Neuropsychology: What is it? Basic scientific discipline that studies how the structure and function of the brain relates to cognition, emotion, and behavior What do we do? Examine how changes in brain influence behavior

10 Neuropsychological Assessment Look on the bright side. For one brief, glorious moment, you forgot you were on the Cubs

11 Neuropsychological Assessment Cognitive domains most implicated in concussion Attention Executive Functioning Processing Speed Memory

12 Neuropsychological Assessment Brief Screening e.g., Standardized Assessment of Concussion (SAC), SCAT2 Computerized Testing (e.g., ImPACT) Traditional Testing Brief Evaluation Comprehensive Evaluation

13 Neuropsychological Assessment Hybrid Approach 1 Pre Injury Baseline Computerized Testing Post Injury Follow-up Computerized Testing Traditional Testing 1 Echemendia, et al., 2013; 2 Echemendia, et al., 2009; 3 McCrea, 2007; 4 AACN, 2007; 5 Herring, et al., 2011

14 Deciding When to Refer Injury & Persistent Symptoms Concussion Clinic Brief Testing Comprehensive Testing

15 Deciding When to Refer Injury & Persistent Symptoms Concussion Clinic 80-90% concussions resolve in 7-10 days 1 May be longer in children and adolescents 2 Physical complaints Headaches, nausea, dizziness, balance problems, sleep disturbance Cognitive complaints concentration, memory, processing speed, wordfinding 1 McCrory, et al. 2013; 2 McCrory, et al., 2005

16 Deciding When to Refer Injury & Persistent Symptoms 14 days to 3 months post injury Physical & cognitive Brief Testing Concussion Clinic No Complications Comprehensive Testing

17 Deciding When to Refer Comprehensive Testing Concussion Clinic For co-occurring complications History of psychiatric, cognitive, developmental, or medical issues Complex injury: LOC > 10 min, Post-traumatic amnesia > 12 hrs after medical stabilization Abnormal imaging

18 Deciding When to Refer Injury & Persistent Symptoms 14 days to 3 months post injury Physical & cognitive Brief Testing > 3 months post injury Concussion Clinic No Complications Comprehensive Testing

19 Traditional Testing: Brief vs Comprehensive ALL TESTING BRIEF COMPREHENSIVE Information gathered: Record review (neuroimaging, baseline testing, school reports, previous testing) Interview with parent/guardian & child Current concussion symptoms Results integrated with developmental, medical and psychosocial history Feedback, recommendations, and education on concussion provided

20 Traditional Testing: Brief vs Comprehensive ALL TESTING BRIEF COMPREHENSIVE One appointment- 2 to 3 hours Assessment: Estimate of baseline functioning Attention & Executive functioning Fluency Processing Speed Memory Mood/Effort

21 Traditional Testing: Brief vs Comprehensive ALL TESTING BRIEF COMPREHENSIVE One or multiple appointments 4 to 8 hours Assessment: Intellectual, academic, and adaptive functioning Neuropsychological domains from brief screen Emotional, behavioral, social functioning

22 Traditional Testing: Brief vs Comprehensive ALL TESTING BRIEF COMPREHENSIVE Review of developmental, medical and psychosocial history Feedback, recommendations, education No complications; Most common Refer 14 days to 3 months post injury One appointment- 2 to 3 hrs Complications/pre-existing factors Refer > 3 months post injury One or multiple appointments- 4 to 8 hrs

23 Neuropsychological Testing Informs Return to play decisions Further referrals Psychotherapy, Vestibular Rehabilitation Therapy, Cognitive Rehabilitation School accommodations Establish plan for graduated return to academics Individualized Education Plan (IEP)/504 Accommodation Plan Student Support Teams (SST)

24 Multidimensional Model of Concussion Assessment 1 Comorbid/ Complicating Factors Concussion History Multidimensional Assessment Symptoms Balance/ Postural Stability 1 Echemendia, et al, 2013 Cognition

25 Preventing Post-Concussion Syndrome PRIOR to injury: 1 Education on psychological symptoms of concussion IN ADDITION to physical Psychological screen at baseline FOLLOWING injury: Seeking medical attention Rest for body AND mind Addressing co-morbid factors 1 Ponsford, et al, 2001

26 Future Directions for Research Baseline data Computerized neuropsychological testing Psychological functioning in athletes How factors influence recovery Concussion in young children Evaluation and management

27 Conclusions Multidimensional approach to concussion management Neuropsychological testing is a key element Cognitive and psychological Computerized neuropsychological testing Baseline, monitoring during acute and post-acute Traditional neuropsychological testing Reserved for athletes with prolonged recoveries Brief vs comprehensive depends on Co-occurring complications, pre-existing factors Cognitive results from neuropsychological testing inform: Return to play, recommendations for school, and biopsychosocial factors

28 Referring to Catalpa Health Website: Catalpahealth.org Referring providers tab Download referral form David Leicht, PhD Linda Steffen, PsyD Concussion Clinic John Oestreicher, PhD, ABPP-CN Jillian Schuh, PhD

29 References Echemendia, R. J., Herring, S., & Bailes, J. (2009). Who should conduct and interpret the neuropsychological assessment in sports-related concussion? Br J Sports Med, 43 Suppl 1 Echemendia, R. J., Iverson, G. L., McCrea, M., Macciocchi, S. N., Gioia, G. A., Putukian, M., & Comper, P. (2013). Advances in neuropsychological assessment of sport-related concussion. Br J Sports Med, 47(5), Herring, S. A., Cantu, R. C., Guskiewicz, K. M., Putukian, M., Kibler, W. B., Bergfeld, J. A.,.. Indelicato, P. A. (2011). Concussion (mild traumatic brain injury) and the team physician: a consensus statement update. Med Sci Sports Exerc, 43(12), Iverson, G. (2012). A biopsychosocial conceptualization of poor outcome from mild traumatic brain injury. In R. Bryant & T. Keane (Eds.), PTSD and mild traumatic brain injury (pp ). New York: Guilford Press. McCrea, M. (Ed.). (2007). Mild traumatic brain injury and postconcussion syndrome: The new evidence base for diagnosis and treatment. New York, NY: Oxford University Press. McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J.,... Schamasch, P. (2005). Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague Br J Sports Med, 39(4), McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R.,... Turner, M. (2013). Consensus statement on Concussion in Sport--the 4th International Conference on Concussion in Sport held in Zurich, November J Sci Med Sport, 16(3), American Academy of Clinical Neuropsychology (2007). American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol, 21(2),

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