Faculty Bibliography

(1) Background: The King-Devick (KD) rapid number naming test is sensitive for concussion diagnosis, with increased test time from baseline as the outcome measure. Eye tracking during KD performance in concussed individuals shows an association between inter-saccadic interval (ISI) (the time between saccades) prolongation and prolonged testing time. This pilot study retrospectively assesses the relation between ISI prolongation during KD testing and cognitive performance in persistently-symptomatic individuals post-concussion. (2) Results: Fourteen participants (median age 34 years; 6 women) with prior neuropsychological assessment and KD testing with eye tracking were included. KD test times (72.6 ± 20.7 s) and median ISI (379.1 ± 199.1 msec) were prolonged compared to published normative values. Greater ISI prolongation was associated with lower scores for processing speed (WAIS-IV Coding, r = 0.72, p = 0.0017), attention/working memory (Trails Making A, r = -0.65, p = 0.006) (Digit Span Forward, r = 0.57, p = -0.017) (Digit Span Backward, r= -0.55, p = 0.021) (Digit Span Total, r = -0.74, p = 0.001), and executive function (Stroop Color Word Interference, r = -0.8, p = 0.0003). (3) Conclusions: This pilot study provides preliminary evidence suggesting that cognitive dysfunction may be associated with prolonged ISI and KD test times in concussion.

Migraine affects over 40 million Americans and is the world's second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.

BACKGROUND/OBJECTIVES/OBJECTIVE:Nonpharmacological interventions, such as biofeedback, cognitive behavioral therapy, and relaxation techniques are Level-A evidence-based treatments for headache. The impact of these interventions is often equivalent to or greater than pharmacological interventions, with fewer side effects. Despite such evidence, the rate of participation in nonpharmacological interventions for headache remains low. Once obstacles to optimizing use of behavioral interventions, such as local access to nonpharmacological treatment and primary headache providers are traversed, identification of barriers contributing to low adherence is imperative given the high levels of disability and cost associated with treating headache disorders. In this review of factors in adults associated with underuse of nonpharmacological interventions, we discuss psychological factors relevant to participation in nonpharmacological treatment, including attitudes and beliefs, motivation for change, awareness of triggers, locus of control, self-efficacy, acceptance, coping styles, personality traits, and psychiatric comorbidities associated with treatment adherence. Finally, future prospects and approaches to optimizing treatment matching and minimizing adherence issues are addressed. METHODS:An interdisciplinary team conducted this narrative review. Neuropsychologists conducted a literature search during the month of July 2017 using a combination of the keywords ("headache" or "migraine") and ("adherence" or "compliance") or "barriers to treatment" or various "psychological factors" discussed in this narrative review. Content experts, a psychiatrist, and a complementary and integrative health specialist provided additional commentary and input to this narrative review resulting in integration of additional noteworthy studies, book chapters and books. RESULTS:Various psychological factors, such as attitudes and beliefs, lack of motivation, poor awareness of triggers, external locus of control, poor self-efficacy, low levels of acceptance, and engagement in maladaptive coping styles can contribute to nonadherence. CONCLUSIONS:To maximize adherence, clinicians can assess and address an individual's level of treatment acceptance, beliefs that may present as barriers, readiness for change, locus of control, self-efficacy and psychiatric comorbidities. Identification of barriers to adherence as well as the application of relevant assessment and intervention techniques have the potential to facilitate adherence and ultimately improve treatment success.

Research Objectives: To investigate the associations between the SCAT3 Cognitive factor with neuropsychological performance measures. Design: Retrospective study of adult patients diagnosed with concussions. Setting: Outpatient concussion center in a major urban medical center. Participants: Participants were 89 patients diagnosed with uncomplicated mild traumatic brain injuries/concussions ages 18 years or older referred for neuropsychological evaluation. Interventions: Neuropsychological assessment. Main Outcome Measures: Sport Concussion Assessment Tool (SCAT3), Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) Digit Span Backward Subscale, WAIS-IV Coding, Delis-Kaplan Executive Function System Verbal Fluency, California Verbal Learning Test II (CVLT-II) Long Delayed Free Recall, Stroop Color and Word Interference score, Trails Making Test B (TMTB). Results: Separated hierarchical multiple regression analyses were computed. Results indicated that a higher SCAT3 cognitive measure was predictive of lower performance on Digit Span Backward Scaled Score (T= -.32, R2 =.23, p=.005), Coding (T= -.31, R2 =.37, p=.004), CVLT-II Long Delayed Recall (T= -.22, R2 =.36, p=.030), and TMTB (T= -.41, R2 =.27, p < .001) after controlling for years of education, gender, age, numbers of prior concussions, and loss of consciousness. Conclusions: Neuropsychological measures examining concentration, visuomotor processing speed, memory, and set shifting are associated with the SCAT3 Cognitive Factor score. The SCAT3 may be a useful tool to identify individuals who may benefit from follow-up and management of cognitive symptoms. While the SCAT3 was designed for athletes, it may be helpful in the general population

Introduction/Rational Effective psychoeducation or CBT interventions for treating patients immediately after concussions at the emergency room or for those later experiencing post-concussion symptoms had been reported (Mittenberg, 1993; Potter & Brown, 2012). However, minimal interventions have been provided for those who experience persistent concussion symptoms during their early recovery phase. This proposed group intervention is tailored for single lifetime concussed patients whose recent injury occurred no more than 8 months ago. Method/Approach The group treatment consists of eight weekly sessions and is being held at an urban medical rehabilitation center. Twenty seven participants attended this intervention over four different cohort groups. Participants completed a questionnaire package prior to and following the completion of the group sessions. The group focuses on psychoeducation during the first phase of treatment, followed by discussing specific symptom domains and appropriate strategies to improve relevant symptoms. The intervention utilizes principles from pacing intervention, cognitive strategies, behavioral modification, and cognitive behavioral therapy to improve patients' stamina, cognition, mood, and lifestyle. Results/Effects Based on our preliminary data, paired t-test indicated increased knowledge of concussions (p < .02), significant reduction of severity of symptoms (p < .01), perceived less impact of concussion on everyday lives (p < .02), and less concern relating to concussions (p < .03). Positive feedback was indicated based on a post-intervention satisfaction survey taken by patients. The drop-out rate was only 11.1%. Conclusions/Limitations Overall, results suggest that this intervention is a therapeutic and cost-effective treatment for concussed patients within the early stage of recovery

PURPOSE OF REVIEW: Post-traumatic headache (PTH) is a common headache type after traumatic brain injury (TBI). There are no FDA approved medications for PTH, and it is unknown how medications can affect the brain's ability to recover from TBI. Thus, we sought to examine the biopsychosocial factors that influence PTH and the non-pharmacologic treatments studied for headache treatment. We also sought to determine if there is literature examining whether the non-pharmacologic treatments influence the biopsychosocial factors. The non-pharmacologic treatments assessed included cognitive behavioral therapy (CBT), biofeedback, progressive muscle relaxation therapy (PMR), acupuncture, and physical therapy (PT). RECENT FINDINGS: Factors associated with prognosis in PTH may include the following: severity of TBI, stress, post-traumatic stress disorder, other psychiatric comorbidities, sociocultural and psychosocial factors, litigation, base rate misattribution, expectation as etiology, and chronic pain. There are few high quality studies on the non-pharmacologic treatments for PTH. Thermal and EMG biofeedback appear to have been examined the most followed by CBT. Studies did not have secondary outcomes examining the psychosocial factors related to PTH. Most of the behavioral studies involved a multi-modality intervention limiting the ability to assess the individual non-pharmacologic interventions we sought to study. There were very few randomized clinical trials evaluating the efficacy of non-pharmacologic interventions. Therefore, future research, which considers the noted biopsychosocial factors, is needed in the field to determine if these interventions reduce PTH.

Research Objectives: Examine gender differences in self-reported postconcussion symptoms among individuals referred for neuropsychological services. Research has shown female gender is associated with increased susceptibility to emotional, physiological, sensory, and cognitive symptom clusters (King, 2014). Few studies have demonstrated which symptom cluster females are more likely to endorse. This study evaluates gender differences in symptomatology subsequent to various causes of concussion as research has shown this has implications for outcomes. Design: Retrospective study of adult concussion patients. Setting: Outpatient concussion center in an urban medical center. Participants: 100 patients (female = 59; mean age = 40.69 years) diagnosed with concussion or Post-Concussion Syndrome (PCS). Falls (33%), motor vehicle injuries (24%), and struck by an object (21%) were the top causes of injury. Interventions: Neuropsychological or psychological assessment. Main Outcome Measure(s): Sport Concussion Assessment Tool (SCAT 3). Results: Results indicated female concussion patients endorsed more physiological and sensory symptoms including nausea/vomiting (t(85.83)=-2.02, p <.05), dizziness (t(91) = -2.17, p <.05), balance problems (t(85.94) = -2.33, p <.05), sensitivity to light (t(91) = -3.18, p <.01 ), and sensitivity to noise (t(91) = -2.30, p <.05) than males. Additionally, females reported experiencing higher total numbers of symptoms (t(54.45)=-2.03, p <.05) and symptom severity (t(91) = -2.29, p <.05 ) than males. No gender differences were found with regard to cognitive, emotional, and sleep symptoms. Conclusions: A gender effect was demonstrated on several physiological and sensory concussion symptoms suggesting females to be more symptomatic than males. Results are consistent with previous findings indicating female athletes reported increased somatic symptoms postconcussion than male athletes. These findings can provide insight for rehabilitation specialists to develop more gender-specific approaches for treating female non-sport concussion patients