Neuropsychological Assessment in Sports-Related Concussion:

Part of a Complex Puzzle

Jillian Schuh, PhD1, 2, John Oestreicher, PhD1, & Linda Steffen, PsyD1

1Catalpa Health 2Department of Neurology,

Medical College of Wisconsin

Contact information: Jillian.schuh@catalpahealth.org

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

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

Acknowledgements

Courtesy of Michael McCrea, PhD, ABPP-CN

Concussion: Integrated Recovery Model

Post-Concussion Syndrome

• Somatic (headache, fatigue, dizziness, sleep disturbance)

• Cognitive (inattention, forgetfulness, slowed processing)

• Affective Symptoms (irritability, disinhibition, lability,

anxiety, depression, apathy)

Post-Concussion Syndrome: A Biopsychosocial Model 1

Neurocognition

Mental Health

Social Factors

Sleep Disturbance

Vestibular Injury

Chronic Pain

Personality Characteristics

Resilience

Vulnerability

Preexisting Mental Health

Substance Abuse

Prior Brain Injuries

Prior Medical/Neurological

1 Adapted from Iverson, 2012

Post Injury Factors Pre Injury Factors

Multidimensional Model of Concussion Assessment 1

Comorbid/ Complicating

Factors

Balance/ Postural Stability

Concussion History

Symptoms

Cognition

Multidimensional Assessment

1 Echemendia, et al, 2013; 2 McCrary, et al., 2013

Cognitive recovery often FOLLOWS symptom resolution! 2

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

“Look on the bright side. For one brief, glorious moment, you forgot you were on the Cubs”

Neuropsychological Assessment

Cognitive domains most implicated in concussion

Attention Executive

Functioning

Processing

Speed Memory

Neuropsychological Assessment

• Brief Screening

– e.g., Standardized Assessment of Concussion (SAC), SCAT2

• Computerized Testing (e.g., ImPACT)

• Traditional Testing

– Brief Evaluation

– Comprehensive Evaluation

Neuropsychological Assessment

Hybrid Approach1

Baseline Computerized

Testing

Pre Injury Post Injury

Follow-up Computerized Testing

Traditional Testing

Neuropsychological Assessment … Neuropsychologist are the professionals best trained to interpret cognitive tests… 2, 3, 4, 5

1 Echemendia, et al., 2013; 2 Echemendia, et al., 2009; 3 McCrea, 2007; 4 AACN, 2007; 5 Herring, et al., 2011

Injury & Persistent Symptoms

Brief Testing

Comprehensive Testing

Concussion Clinic

Deciding When to Refer

Deciding When to Refer

Concussion Clinic

Injury & Persistent Symptoms

• 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, word-

finding 1 McCrory, et al. 2013; 2 McCrory, et al., 2005

Deciding When to Refer

Injury & Persistent Symptoms

• Physical & cognitive

Brief Testing

Comprehensive Testing

14 days to 3 months post injury

Concussion Clinic

• No Complications

Deciding When to Refer

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

Comprehensive Testing

Concussion Clinic

Deciding When to Refer

Injury & Persistent Symptoms

• Physical & cognitive

Brief Testing

Comprehensive Testing

14 days to 3 months post injury

> 3 months post injury

Concussion Clinic

• No Complications

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

ALL TESTING

BRIEF

COMPREHENSIVE

• One appointment- 2 to 3 hours

• Assessment: – Estimate of baseline functioning

– Attention & Executive functioning

– Fluency

– Processing Speed

– Memory

– Mood/Effort

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

Traditional Testing: Brief vs Comprehensive

• Review of developmental, medical and psychosocial history

• Feedback, recommendations, education ALL

TESTING

BRIEF

COMPREHENSIVE

• Complications/pre-existing factors

• Refer > 3 months post injury

• One or multiple appointments- 4 to 8 hrs

• No complications; Most common

• Refer 14 days to 3 months post injury

• One appointment- 2 to 3 hrs

Traditional Testing: Brief vs Comprehensive

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)

Multidimensional Model of Concussion Assessment 1

Comorbid/ Complicating

Factors

Balance/ Postural Stability

Concussion History

Symptoms

Cognition

Multidimensional Assessment

1 Echemendia, et al, 2013

Preventing Post-Concussion Syndrome

• PRIOR to injury: 1

– Education on psychological symptoms of concussion IN ADDITION to physical

• FOLLOWING injury:

– Seeking medical attention

– Rest for body AND mind

– Addressing co-morbid factors

1 Ponsford, et al, 2001

Future Directions for Research

• Baseline data

– Computerized neuropsychological testing

• Psychological functioning in athletes

– How factors influence recovery

• Concussion in young children

– Evaluation and management

Conclusions • Multidimensional approach to concussion management

– Neuropsychological testing is a key element

• Cognitive and psychological

• One piece used in return-to-play decisions

• Traditional neuropsychological testing

– 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

Referring to Catalpa Health

• Website: Catalpahealth.org

– Referring providers tab Download referral form

Concussion Clinic

David Leicht, PhD

John Oestreicher, PhD, ABPP-CN

Linda Steffen, PsyD

Jillian Schuh, PhD

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), 294-298.

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--2011 update. Med Sci Sports Exerc, 43(12), 2412-2422.

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. 37-60). 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 2004. Br J Sports Med, 39(4), 196-204.

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 2012. J Sci Med Sport, 16(3), 178-189.

American Academy of Clinical Neuropsychology (2007). American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol, 21(2), 209-231.