Medical Symptom Validity Test Performance Following Moderate-Severe Traumatic Brain Injury: Expectations Based on Orientation Log Classification.

OBJECTIVE: This study examined performance on the Medical Symptom Validity test (MSVT) during acute rehabilitation for moderate-severe traumatic brain injury (TBI) stratified by Orientation Log (O-Log) scores. METHOD: Participants were 77 prospectively enrolled persons who sustained moderate-severe TBI and were acutely hospitalized secondary to the cognitive, medical and physical sequelae of their TBI. Participants were administered neuropsychological metrics, the O-Log and the MSVT a mean of 44 days post injury. RESULTS: Significantly lower neurocognitive test scores were observed among participants who remained in post-traumatic amnesia (O-Log scores ranging from 20 to 24) versus those who were oriented (O-Log scores ranging from 25 to 30). MSVT performance was lower among participants who remained in post-traumatic amnesia. When participants O-Log scores were unimpaired (30), performance on the MSVT was also unimpaired on immediate recognition (IR) and delayed recognition (DR). A small percentage of participants performed below MSVT interpretive expectations on CNS. As O-Log scores decreased, MSVT performance also declined on some, but not all MSVT metrics. The sample as a whole performed at or above expectations on MSVT criterion B2 (IR) = 96.6%; (DR) = 94.8%; consistency (CNS) = 92.9%; paired associate (PA) = 86.4% and delayed free recall (FR) = 46.8%. CONCLUSIONS: MSVT performance stratified by O-Log scores provides basal expectation levels for persons with acute, moderate-severe impairment in cognitive skills secondary to TBI. Our data demonstrate that persons with significant neurocognitive impairment who are oriented generally perform at or above MSVT interpretive guidelines.

The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one.

CONTEXT: A battery of clinical measures of neurocognition, balance and symptoms has been recommended for the management of sport concussion (SC) but is based on variable evidence. OBJECTIVE: To examine the sensitivity and specificity of a battery of tests to assess SC in college athletes. DESIGN: Cross-sectional. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Division 1 athletes diagnosed with a SC (n=40) who were 20.2±1.60 years of age and 180.5±11.12 cm tall and healthy athletes (n=40) who were 19.0±0.93 years of age and 179.1±11.39 cm tall were enrolled. INTERVENTIONS: Participants were administered Immediate Postconcussion Assessment and Cognitive Test (ImPACT), the Sensory Organization Test (SOT) and the Revised Head Injury Scale (HIS-r) prior to and up to 24 h following injury between the 2004 and 2014 sport seasons. Sensitivity and specificity were calculated using predictive discriminant analyses (PDA) and clinical interpretation guidelines. MAIN OUTCOME MEASURES: Outcome measures included baseline and postinjury ImPACT, SOT and HIS-r composite scores. RESULTS: Using PDA, each clinical measure's sensitivity ranged from 55.0% to 77.5% and specificity ranged from 52.5% to 100%. The test battery possessed a sensitivity and specificity of 80.0% and 100%, respectively. Using clinical interpretation guidelines, sensitivity ranged from 55% to 97.5% individually, and 100% when combined. CONCLUSIONS: Our results support a multidimensional approach to assess SC in college athletes which correctly identified 80-100% of concussed participants as injured. When each test was evaluated separately, up to 47.5% of our sample was misclassified. Caution is warranted when using singular measures to manage SC.

A Preliminary Formula to Predict Timing of Symptom Resolution for Collegiate Athletes Diagnosed With Sport Concussion.

CONTEXT: Symptom presentation and recovery after sport concussion (SC) are variable. Empirically based models documenting typical symptom duration would assist health care providers in managing return to play after SC. OBJECTIVE: To develop a prediction model for SC symptom duration. DESIGN: Cross-sectional study. SETTING: Two National Collegiate Athletic Association Division I university laboratories. PATIENTS OR OTHER PARTICIPANTS: Seventy-six (51 male and 25 female) concussed athletes with an average age of 19.5 ± 1.65 years who were evaluated within 24 hours of diagnosis. INTERVENTION(S): Participants completed the Revised Head Injury Scale (HIS-r), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), and Sensory Organization Test within 24 hours of SC diagnosis. MAIN OUTCOME MEASURE(S): A stepwise multivariate regression incorporating ImPACT and Sensory Organization Test composites and HIS-r symptom severity-duration was used to predict the number of days athletes reported symptoms after SC. The resulting regression formula was cross-validated using the Stine cross-validation coefficient. RESULTS: The final formula consisted of the HIS-r's self-reported neck pain, drowsiness, tingling, and nervousness duration and ImPACT total symptom severity (R = 0.62, R(2) = 39%, R(2)(adj) = 34.2%, P < .001). Approximately 29% (R(2)(cv) = 29%) of the variance associated with total days symptomatic after SC was explained by our preliminary formula when cross-validated. The current formula correctly identified 76% of participants who recovered within 10 days of injury. CONCLUSIONS: Our results suggest that self-reported duration of 4 symptoms during the initial 24 hours after injury along with total symptom severity as measured by ImPACT accounted for a considerable amount of variance associated with days symptomatic after SC in collegiate athletes. Until the formula is cross-validated in a college-aged sample, caution is warranted in using it clinically.

The impact of mild traumatic brain injury on cognitive functioning following co-occurring spinal cord injury.

Meta-analytic studies have shown that mild traumatic brain injury (MTBI) has relatively negligible effects on cognitive functioning at 90 or more days post-injury. Few studies have prospectively examined the effects of MTBI in acute physical trauma populations. This prospective, cohort study compared the cognitive performance of persons who sustained a spinal cord injury (SCI) and a co-occurring MTBI (N = 53) to persons who sustained an SCI alone (N = 64) between 26 and 76 days (mean = 46) post-injury. The presence of MTBI was determined based on acute medical record review using a standardized algorithm. Primary outcome measures were seven neuropsychological tests that evaluated visual, verbal, and working memory, perceptual reasoning, and processing speed that controlled for potential upper extremity impairment. Persons who sustained SCI with or without MTBI had lower than expected performance across all neuropsychological tests, on average about 1 SD below the mean. Analysis of covariance indicated that persons with MTBI did not evidence greater impairment on any neuropsychological test. The aggregated effect size (Cohen's d) was -0.16. The strongest predictors of neuropsychological test scores were education, race, history of learning problems, and days from injury to rehabilitation admission. MTBI did not predict performance on any neuropsychological test. These findings are consistent with other controlled studies that indicate a single MTBI has negligible long-term impacts on cognition.

Advances in neuropsychological assessment of sport-related concussion.

OBJECTIVE: To critically review the literature from the past 12 years regarding the following key issues in sports-related neuropsychological assessment: (1) the advantages and disadvantages of different neuropsychological assessment modalities; (2) the evidence for and against the current paradigm of baseline/postinjury testing; (3) the role of psychological factors in the evaluation and management of concussion; (4) advances in the neuropsychological assessment of children; (5) multi-modal assessment paradigms; (6) the role of the neuropsychologist as part of the sports healthcare team and (6) the appropriate administration and interpretation of neuropsychological tests. DESIGN: Targeted computerised literature review (MEDLINE, PubMed, CINAHL and PsychInfo) from 2000 to the present using key words: neuropsychological, neurocognitive, assessment, testing, concussion and sports. RESULTS: More than 2600 articles were identified using key word searches of the databases, including many duplicates. Several books were also reviewed. The articles were pared down for review if they specifically addressed the key areas noted above. CONCLUSIONS: Traditional and computerised neuropsychological tests are useful in the evaluation and management of concussion. Brief cognitive evaluation tools are not substitutes for formal neuropsychological assessment. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing. Although scant, research suggests that psychological factors may complicate and prolong recovery from concussion in some athletes. Age-appropriate symptom scales for children have been developed but research into age-appropriate tests of cognitive functions lags behind. Neuropsychologists are uniquely qualified to interpret neuropsychological tests and can play an important role within the context of a multifaceted-multimodal approach to manage sports-related concussions.

Developing and evaluating prediction models in rehabilitation populations.

This article presents a 3-part framework for developing and evaluating prediction models in rehabilitation populations. First, a process for developing and refining prognostic research questions and the scientific approach to prediction models is presented. Primary components of the scientific approach include the study design and sampling of patients, outcome measurement, selecting predictor variable(s), minimizing methodologic sources of bias, assuring a sufficient sample size for statistical power, and selecting an appropriate statistical model. Examples focus on prediction modeling using samples of rehabilitation patients. Second, a brief overview for statistically building and validating multivariable prediction models is provided, which includes the following 7 steps: data inspection, coding of predictors, model specification, model estimation, model performance, model validation, and model presentation. Third, we propose a set of primary considerations for evaluating prediction model studies using specific quality indicators as criteria to help stakeholders evaluate the quality of a prediction model study. Lastly, we offer perspectives on the future development and use of rehabilitation prediction models.

Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement.

Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed at developing evidence-based approaches to the evaluation and management of sport-related concussion (SRC). These efforts have directly impacted current policy on strategies for injury assessment and return-to-play by athletes after concussion. Many states are considering legislation requiring (a) education of athletes, parents, coaches, and school/organization officials on the recognition, evaluation, and management of SRCs; (b) removal from play of any youth athlete that is suspected of having sustained a concussion; and (c) not allowing the student to return to participation until the student is evaluated and cleared for return to participation in writing by an appropriate healthcare professional. It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology (ABN), Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) that neuropsychologists should be included among the licensed healthcare professionals authorized to evaluate, clinically manage, and provide return to play clearance for athletes who sustain a SRC.

Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement.

Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed at developing evidence-based approaches to the evaluation and management of sport-related concussion. These efforts have directly impacted current policy on strategies for injury assessment and return-to-play by athletes after concussion. Many states are considering legislation requiring (a) education of athletes, parents, coaches, and school/organization officials on the recognition, evaluation, and management of sport-related concussions; (b) removal from play of any youth athlete that is suspected of having sustained a concussion; and (c) not allowing the student to return to participation until the student is evaluated and cleared for return to participation in writing by an appropriate healthcare professional. It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Neuropsychology (ABN), Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) that neuropsychologists should be included among the licensed health care professionals authorized to evaluate, clinically manage, and provide return to play clearance for athletes who sustain a sport-related concussion.

Investigation of baseline self-report concussion symptom scores.

CONTEXT: Self-reported symptoms (SRS) scales comprise one aspect of a multifaceted assessment of sport-related concussion. Obtaining SRS assessments before a concussion occurs assists in determining when the injury is resolved. However, athletes may present with concussion-related symptoms at baseline. Thus, it is important to evaluate such reports to determine if the variables that are common to many athletic environments are influencing them. OBJECTIVE: To evaluate the influence of a history of concussion, sex, acute fatigue, physical illness, and orthopaedic injury on baseline responses to 2 summative symptom scales; to investigate the psychometric properties of all responses; and to assess the factorial validity of responses to both scales in the absence of influential variables. DESIGN: Cross-sectional study. SETTING: Athletic training facilities of 6 National Collegiate Athletic Association institutions. PATIENTS OR OTHER PARTICIPANTS: The sample of 1065 was predominately male (n = 805) collegiate athletes with a mean age of 19.81 +/- 1.53 years. MAIN OUTCOME MEASURE(S): Participants completed baseline measures for duration and severity of concussion-related SRS and a brief health questionnaire. RESULTS: At baseline, respondents reporting a previous concussion had higher composite scores on both scales (P

The impact of diabetes mellitus on stroke acute rehabilitation outcomes.

OBJECTIVE: To examine the impact of diabetes mellitus (DM) on functional outcomes after acute rehabilitation for cerebrovascular accident (CVA). DESIGN: A retrospective research design was used to analyze outcomes in patients with a primary diagnosis of unilateral stroke (n = 367) admitted to an urban, acute rehabilitation center in the Southeastern United States. RESULTS: Multivariable hierarchical regression revealed that DM did not contribute statistically significant variance to stroke acute rehabilitation prediction models. Rehabilitation admission functioning scores, rehabilitation length of stay, age, and stroke type were significant predictors of poststroke rehabilitation motor outcomes (r2 = 0.603) and cognitive outcomes (r2 = 0.712). Diabetes also had no significant impact on acute stroke rehabilitation lengths of stay or rehabilitation discharge setting. CONCLUSIONS: Diabetes does not seem to significantly impact short-term acute rehabilitation outcomes after stroke. Persons with diabetes who suffer a stroke seem to benefit and improve during their acute rehabilitation stay at levels equivalent to peers who are not diagnosed with diabetes. Future research should examine the impact of diabetes subtypes and undiagnosed diabetes on short- and long-term outcomes.

Sensitivity of the concussion assessment battery.

OBJECTIVE: Sports medicine clinicians commonly use multiple tests when evaluating patients with concussion. The specific tests vary but often include symptom inventories, posturography, and neurocognitive examinations. The sensitivity of these tests to concussion is vital in reducing the risk for additional injury by prematurely returning an athlete to play. Our study investigated the sensitivity of concussion-related symptoms, a postural control evaluation, and neurocognitive functioning in concussed collegiate athletes. METHODS: From 1998 to 2005, all high-risk athletes completed a baseline concussion-assessment battery that consisted of a self-reported symptom inventory, a postural control evaluation, and a neurocognitive assessment. Postconcussion assessments were administered within 24 hours of injury to 75 athletes who had physician-diagnosed concussion. Individual tests and the complete battery were evaluated for sensitivity to concussion. RESULTS: The computerized Immediate Post-Concussion Assessment and Cognitive Testing and HeadMinder Concussion Resolution Index (neurocognitive tests) were the most sensitive to concussion (79.2 and 78.6%, respectively). These tests were followed by self-reported symptoms (68.0%), the postural control evaluation (61.9%), and a brief pencil-and-paper assessment of neurocognitive function (43.5%). When the complete battery was assessed, sensitivity exceeded 90%. CONCLUSION: Currently recommended concussion-assessment batteries accurately identified decrements in one or more areas in most of the athletes with concussion. These findings support previous recommendations that sports-related concussion should be approached through a multifaceted assessment with components focusing on distinct aspects of the athlete's function.

Neurocognitive performance of concussed athletes when symptom free.

CONTEXT: Concussed athletes may underreport concussion-related symptoms in order to expedite return to play. Whether neurocognitive impairments persist once concussion-related symptoms resolve has yet to be determined. Reliance on athlete-reported, postconcussion symptoms when making return-to-play decisions may expose athletes to subsequent injury if complete recovery has not occurred. OBJECTIVE: To evaluate the presence of neurocognitive decrements in concussed athletes no longer reporting concussion-related symptoms. DESIGN: Within-groups design. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-one National Collegiate Athletic Association Division I collegiate athletes (16 men, 5 women). Age = 19.81 +/- 1.25 years, height = 180.95 +/- 10.62 cm, mass = 93.66 +/- 27.60 kg, and previous concussions = 1.76 +/- 2.02. MAIN OUTCOME MEASURE(S): The ImPACT concussion assessment test was administered to concussed athletes at baseline, when symptomatic (within 72 hours of injury), and when asymptomatic. Index scores of verbal memory, visual memory, visual-motor speed, reaction time, and concussion-related symptoms were recorded at each session. The Symptom Assessment Scale was administered daily after injury to establish when the athlete became asymptomatic. RESULTS: When assessed within 72 hours of concussion, 81% of the athletes showed deficits on at least 1 ImPACT variable. At the asymptomatic time point, 38% of the concussed athletes continued to demonstrate neurocognitive impairment on at least 1 ImPACT variable. CONCLUSIONS: Neurocognitive decrements may persist when athletes no longer report concussion-related symptoms. The exclusive use of symptom reports in making a return-to-play decision is not advised. A multifaceted approach to concussion assessment that includes evaluation of a myriad of functions is warranted.

Test-retest reliability of computerized concussion assessment programs.

CONTEXT: Computer-based neurocognitive assessment programs commonly are used to assist in concussion diagnosis and management. These tests have been adopted readily by many clinicians based on existing test-retest reliability data provided by test developers. OBJECTIVE: To examine the test-retest reliability of 3 commercially available computer-based neurocognitive assessments using clinically relevant time frames. DESIGN: Repeated-measures design. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: 118 healthy student volunteers. MAIN OUTCOME MEASURE(S): The participants completed the ImPACT, Concussion Sentinel, and Headminder Concussion Resolution Index tests on 3 days: baseline, day 45, and day 50. Each participant also completed the Green Memory and Concentration Test to evaluate effort. Intraclass correlation coefficients were calculated for all output scores generated by each computer program as an estimate of test-retest reliability. RESULTS: The intraclass correlation coefficient estimates from baseline to day 45 assessments ranged from .15 to .39 on the ImPACT, .23 to .65 on the Concussion Sentinel, and .15 to .66 on the Concussion Resolution Index. The intraclass correlation coefficient estimates from the day 45 to day 50 assessments ranged from .39 to .61 on the ImPACT, .39 to .66 on the Concussion Sentinel, and .03 to .66 on the Concussion Resolution Index. All participants demonstrated high levels of effort on all days of testing, according to Memory and Concentration Test interpretive guidelines. CONCLUSIONS: Three contemporary computer-based concussion assessment programs evidenced low to moderate test-retest reliability coefficients. Our findings do not appear to be due to suboptimal effort or other factors related to poor test performance, because persons identified by individual programs as having poor baseline data were excluded from the analyses. The neurocognitive evaluation should continue to be part of a multifaceted concussion assessment program, with priority given to those scores showing the highest reliability.

Victoria Symptom Validity Test performance in acute severe traumatic brain injury: implications for test interpretation.

Effort testing has become commonplace in clinical practice. Recent research has shown that performance on effort tests is highly correlated with performance on neuropsychological measures. Clinical application of effort testing is highly dependent on research derived interpretive guidelines. The Victoria Symptom Validity Test (VSVT) is one of many measures currently used in clinical practice. The VSVT has recommended interpretive guidelines published in the test manual, but the samples used in developing interpretive guidelines are small and heterogeneous and concern has been expressed regarding high false negative rates. In this study, a homogeneous sample of acute, severely brain injured persons were used to assess the sensitivity of the VSVT. Results confirmed that acute, severely brain injured persons (N=71) perform very well on the VSVT. The severe brain injury population is 99% likely to have between 44.1 and 46.8 correct VSVT Combined Score responses. While the VSVT was insensitive to memory dysfunction, the presence of severe visual perceptual (Benton Visual Form Discrimination Score<21) and verbal fluency (Controlled Oral Word Association Score<15) deficits predicted poor performance on the VSVT. These results provide further evidence that performance expectations currently incorporated in the VSVT manual interpretative criteria are too conservative. Empirically based alternative criteria for interpreting VSVT Combined Scores in the TBI population are presented.

Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries.

OBJECTIVE: This study was undertaken to determine if persons who sustain a spinal cord injury (SCI) and co-morbid brain injury (dual diagnosis [DDS]) evidence smaller functional gains and experience significantly longer rehabilitation lengths of stay than persons with only an SCI. DESIGN: This retrospective comparison study was performed at a 100-bed rehabilitation hospital specializing in acute SCI and traumatic brain injury rehabilitation. Summary scale outcome data of persons who sustained an SCI were compared with outcome data of a group of persons with a DDS. Comparisons were established by matching groups principally on level of SCI and admission Motor FIM trade mark score and secondarily on education, sex, and age. Outcome measures included admission Motor and Cognitive FIM score, discharge Motor and Cognitive FIM score, Motor and Cognitive FIM change, length of stay, and rehabilitation charges. RESULTS: Persons with a DDS evidenced a significantly more impaired Cognitive FIM score at admission and discharge from rehabilitation. Persons with a DDS also achieved a significantly lower Motor FIM change than persons with SCI. There were no significant differences between DDS and SCI groups regarding Cognitive FIM change, length of stay, or rehabilitation charges. Injury severity as defined by the Glasgow Coma Scale or intracranial lesions did not predict response to treatment in the DDS group. CONCLUSION: Persons with a DDS achieved smaller functional gains during rehabilitation than peers with SCI. Brain injuries seem to limit functional gains, although the relationship between brain injury severity and functional change is not linear. Prospective studies are needed to identify factors limiting functional gains in rehabilitation and assist in developing specific treatment programs for persons with SCI and brain injury.

Multiple Concussions and Neuropsychological Functioning in Collegiate Football Players.

OBJECTIVE: To document neurocognitive and neurobehavioral consequences of 1 versus 2 concussions. DESIGN AND SETTING: Nonequivalent, pretest-posttest cohort design with multiple dependent measures. Participants were selected from a large sample of athletes who participated in a comprehensive, multiuniversity study of football-related concussion. SUBJECTS: College football players who sustained 1 and 2 grade 1 concussive injuries were matched for age, education, and duration of competitive football. MEASUREMENTS: Neuropsychological tests and symptoms checklists. RESULTS: Multivariate analysis of variance did not show a statistically significant difference in test performance between players with 1 or 2 concussions. Chi square analyses revealed that concussions significantly increased the number of symptom complaints, but symptoms returned to baseline by 10 days postinjury. The effects of 2 injuries did not appear to be significantly greater than that of a single injury. Differences in response to concussion were observed. CONCLUSIONS: Neurocognitive and neurobehavioral consequences of 2 concussions did not appear to be significantly different from those of 1 concussion, but methodologic issues place limitations on data interpretation. Additional studies are needed to clarify the neuropsychological consequences of multiple concussions.