Issues Associated With Repeated Neuropsychological Assessment
Neuropsychological Assessment in - Affinity Health · A Biopsychosocial Model 1 ......
Transcript of Neuropsychological Assessment in - Affinity Health · A Biopsychosocial Model 1 ......
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: [email protected]
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
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.