Faculty Bibliography

Neuropsychologists regularly conduct sport-related concussion (SRC) evaluations, although research has not tracked these assessment practices. As part of a survey of neuropsychological test usage, we analyzed data from 215 neuropsychologists who conduct SRC evaluations. Only 15% reported conducting baseline assessments of athletes as part of a sports program and 92% evaluate athletes' post-concussion without baseline data. The majority of respondents use a full battery, considered the most reliable approach for assessing concussion symptoms in athletes. Only 6% use computerized tests exclusively (>50% ImPACT). We discuss the implications of these results and address challenges faced by neuropsychologists who perform SRC evaluations.

OBJECTIVES: The aim of this study was to evaluate the reliability and validity of three computerized neurocognitive assessment tools (CNTs; i.e., ANAM, DANA, and ImPACT) for assessing mild traumatic brain injury (mTBI) in patients recruited through a level I trauma center emergency department (ED). METHODS: mTBI (n=94) and matched trauma control (n=80) subjects recruited from a level I trauma center emergency department completed symptom and neurocognitive assessments within 72 hr of injury and at 15 and 45 days post-injury. Concussion symptoms were also assessed via phone at 8 days post-injury. RESULTS: CNTs did not differentiate between groups at any time point (e.g., M 72-hr Cohen's d=-.16, .02, and .00 for ANAM, DANA, and ImPACT, respectively; negative values reflect greater impairment in the mTBI group). Roughly a quarter of stability coefficients were over .70 across measures and test-retest intervals in controls. In contrast, concussion symptom score differentiated mTBI vs. control groups acutely), with this effect size diminished over time (72-hr and day 8, 15, and 45 Cohen's d=-.78, -.60, -.49, and -.35, respectively). CONCLUSIONS: The CNTs evaluated, developed and widely used to assess sport-related concussion, did not yield significant differences between patients with mTBI versus other injuries. Symptom scores better differentiated groups than CNTs, with effect sizes weaker than those reported in sport-related concussion studies. Nonspecific injury factors, and other characteristics common in ED settings, likely affect CNT performance across trauma patients as a whole and thereby diminish the validity of CNTs for assessing mTBI in this patient population. (JINS, 2017, 23, 293-303).

The differential contribution of medial-temporal lobe regions to verbal declarative memory is debated within the neuroscience, neuropsychology, and cognitive psychology communities. We evaluate whether the extent of surgical resection within medial-temporal regions predicts longitudinal verbal learning and memory outcomes. This single-center retrospective observational study involved patients with refractory temporal lobe epilepsy undergoing unilateral anterior temporal lobe resection from 2007 to 2015. Thirty-two participants with Engel Classes 1 and 2 outcomes were included (14 left, 18 right) and followed for a mean of 2.3 years after surgery (+/-1.5 years). Participants had baseline and postsurgical neuropsychological testing and high-resolution T1-weighted MRI scans. Postsurgical lesions were manually traced and coregistered to presurgical scans to precisely quantify resection extent of medial-temporal regions. Verbal learning and memory change scores were regressed on hippocampal, entorhinal, and parahippocampal resection volume after accounting for baseline performance. Overall, there were no significant differences in learning and memory change between patients who received left and right anterior temporal lobe resection. After controlling for baseline performance, the extent of left parahippocampal resection accounted for 27% (p = .021) of the variance in verbal short delay free recall. The extent of left entorhinal resection accounted for 37% (p = .004) of the variance in verbal short delay free recall. Our findings highlight the critical role that the left parahippocampal and entorhinal regions play in recall for verbal material.

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

PURPOSE OF REVIEW: Post-traumatic headache (PTH) is a secondary headache disorder following traumatic brain injury. We sought to examine the recent literature on PTH and associated cognitive, psychiatric, and sleep conditions to understand the latest findings about the associated conditions and available screening tools, and to understand the available treatment options for PTH. RECENT FINDINGS: Up to one third of PTH patients may have depression and about one quarter may have insomnia. Anxiety and cognitive issues are also common. While there are few studies examining abortive medications for PTH, recent studies of preventive medications examine the efficacy of topiramate, and topiramate may be better than other oral preventive medications. Other currently investigated treatments include nerve blocks, onabotulinum toxin A, transmagnetic stimulation, and behavioral therapy (biofeedback). Due to an expanded focus on and knowledge of concussion and PTH, comorbid psychiatric, cognitive, and sleep issues have become more widely acknowledged and studied. However, more high-quality studies must be conducted to examine the underlying pathophysiology of PTH and associated symptoms and to determine the most effective abortive and preventive treatment options.

BACKGROUND: The Sport Concussion Assessment Tool-3 (SCAT3) facilitates sideline clinical assessments of concussed athletes. Yet, there is little published research on clinically relevant metrics for the SCAT3 as a whole. PURPOSE: We documented the psychometric properties of the major SCAT3 components (symptoms, cognition, balance) and derived clinical decision criteria (ie, reliable change score cutoffs and normative conversation tables) for clinicians to apply to cases with and without available preinjury baseline data. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: High school and collegiate athletes (N = 2018) completed preseason baseline evaluations including the SCAT3. Re-evaluations of 166 injured athletes and 164 noninjured controls were performed within 24 hours of injury and at 8, 15, and 45 days after injury. Analyses focused on predictors of baseline performance, test-retest reliability, and sensitivity and specificity of the SCAT3 using either single postinjury cutoffs or reliable change index (RCI) criteria derived from this sample. RESULTS: Athlete sex, level of competition, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), and estimated verbal intellectual ability (but not concussion history) were associated with baseline scores on >/=1 SCAT3 components (small to moderate effect sizes). Female sex, high school level of competition (vs college), and ADHD were associated with higher baseline symptom ratings (d = 0.25-0.32). Male sex, ADHD, and LD were associated with lower baseline Standardized Assessment of Concussion (SAC) scores (d = 0.28-0.68). Male sex, high school level of competition, ADHD, and LD were associated with poorer baseline Balance Error Scoring System (BESS) performance (d = 0.14-0.26). After injury, the symptom checklist manifested the largest effect size at the 24-hour assessment (d = 1.52), with group differences diminished but statistically significant at day 8 (d = 0.39) and nonsignificant at day 15. Effect sizes for the SAC and BESS were small to moderate at 24 hours (SAC: d = -0.36; modified BESS: d = 0.46; full BESS: d = 0.51) and became nonsignificant at day 8 (SAC) and day 15 (BESS). Receiver operating characteristic curve analyses demonstrated a stronger discrimination for symptoms (area under the curve [AUC] = 0.86) than cognitive and balance measures (AUCs = 0.58 and 0.62, respectively), with comparable discrimination of each SCAT3 component using postinjury scores alone versus baseline-adjusted scores (P = .71-.90). Normative conversion tables and RCI criteria were created to facilitate the use of the SCAT3 both with and without baseline test results. CONCLUSION: Individual predictors should be taken into account when interpreting the SCAT3. The normative conversion tables and RCIs presented can be used to help interpret concussed athletes' performance both with and without baseline data, given the comparability of the 2 interpretative approaches.

OBJECTIVE: To determine the degree to which preinjury and acute postinjury psychosocial and injury-related variables predict symptom duration following sport-related concussion. METHODS: A total of 2,055 high school and collegiate athletes completed preseason evaluations. Concussed athletes (n = 127) repeated assessments serially (<24 hours and days 8, 15, and 45) postinjury. Cox proportional hazard modeling was used to predict concussive symptom duration (in days). Predictors considered included demographic and history variables; baseline psychological, neurocognitive, and balance functioning; acute injury characteristics; and postinjury clinical measures. RESULTS: Preinjury somatic symptom score (Brief Symptom Inventory-18 somatization scale) was the strongest premorbid predictor of symptom duration. Acute (24-hour) postconcussive symptom burden (Sport Concussion Assessment Tool-3 symptom severity) was the best injury-related predictor of recovery. These 2 predictors were moderately correlated (r = 0.51). Path analyses indicated that the relationship between preinjury somatization symptoms and symptom recovery was mediated by postinjury concussive symptoms. CONCLUSIONS: Preinjury somatization symptoms contribute to reported postconcussive symptom recovery via their influence on acute postconcussive symptoms. The findings highlight the relevance of premorbid psychological factors in postconcussive recovery, even in a healthy athlete sample relatively free of psychopathology or medical comorbidities. Future research should elucidate the neurobiopsychosocial mechanisms that explain the role of this individual difference variable in outcome following concussive injury.