Alina K. Fong, PhDClinical Neuropsychologist

Diagnosis and Treatment of Closed Head Injury:Sifting through the Quagmire of Concussions/Mild TBI

1) Identifying the differences between structural and functional MRI

2)Not all fMRIs are created equal: Learning about functional NCI and its implications for diagnosis with concussions

3) Sensivity and Specificity of CFX mTBI diagnoses

4) Determining some facts and fictions re: mTBI

5)Learning about the CognitiveFX Concussion Treatment Method

BONUS: Can we detect Malingering in this population???

Structural MRI reveals brain anatomy.

Functional NCI (fNCI) reveals brain function.

Structural MRI vs. Functional NCI

Structural MRI reveals brain anatomy.

Functional NCI (fNCI) reveals brain function.

Structural MRI vs. Functional NCI

Functional NCI

We offer unique fNCI application

Standard fMRI

Pre-surgical brain mappingResearch (group averaging)

Limited clinical use1, maybe 2 tasks and limited areas of

focus

fNCI

10 years of development6 comprehensive tasks that measure all

areas of cognitionOur tests cover 57 distinct brain regionsNormative Database - We know what

NORMAL IS! Encapsulates all forms of brain injuryConcussion database (+1,000 tests

administered and collected data)Diagnostic accuracy for concussion

over 98%Used to target treatment on specific cognitive areas, speeding up return to

playRecovery can be objectively measured

Unlimited applications: ADD, MS, Medication Effects, Alzheimer’s, "Chemo

Brain," etc.

Recent Notus Publications  

Bigler, E.D., Allen, M.D., Stimac, G.K, (2012).  MRI and functional MRI. In Simpson, J.R.(Ed.) Neuroimaging in Forensic Psychiatry: From the clinic to the courtroom. Wiley-Blackwell Press.        Abstract Woon, F.L., Allen, M.D., Hedges, D., Miller, C. (2012). The functional magnetic resonance imaging-based verbal fluency test in Obsessive Compulsive Disorder. Neurocase.   Abstract Allen, M.D., Hedges, D.W., Farrer, T.J., and Larson, M.J. (2012). Assessment of Brain Activity during Memory Encoding in a Narcolepsy Patient On and Off Modafinil using Normative fMRI data. Neurocase, 18, 13-25.   Abstract Allen, M.D., Owens, T.E., Fong, A.K., Richards, D.R. (2011). A Functional Neuroimaging Analysis of the Trail Making Test-B: Implications for Clinical Application. Behavioural Neurology, 24, 159-171.   Abstract Allen, M.D., Wu, T.C., & Bigler, E., (2011). Traumatic Brain Injury Alters Word Memory Test Performance by Slowing Response Time and Increasing Cortical Activation: An fMRI Study of a Symptom Validity Test. Psychological Injury and Law, 4, 140-146.   Abstract Larsen, J.D., Allen, M.D., Bigler, E., Goodrich-Hunsaker, N., & Hopkins, R. (2010) Different patterns of cerebral activation in genuine and malingered cognitive effort during performance on the Word Memory Test. Brain Injury, 24, 89-99.   Abstract Wu, T.C., Allen, et al. (2010). Functional Neuroimaging of Symptom Validity Testing in Traumatic Brain Injury. Psychological Injury and Law, 3, 50-62.   Abstract Garn, C.L., Allen, M.D., Larsen, J.D. (2009). An fMRI study of sex differences in brain activation during object naming. Cortex, 45, 610-618.   Abstract Allen, M.D. & Fong A. (2008a). Clinical Application of Standardized Cognitive Assessment using fMRI. I. Matrix Reasoning. Behavioural Neurology, 20, 127-140.   Abstract Allen, M.D. & Fong A. (2008b). Clinical Application of Standardized Cognitive Assessment using fMRI. II. Verbal Fluency. Behavioural Neurology, 20, 141-152.   Abstract Allen, M.D., Bigler, E., Larsen, J., Goodrich-Hunsaker, N., & Hopkins, R. (2007). Functional neuroimaging evidence for high cognitive effort on the Word Memory Test in the absence of external incentives. Brain Injury, 21, 1425-1428.   Abstract

Scientific and Clinical Acceptance

Tests used for neuropsychological assessments are being adapted for administration during functional neuroimaging (Allen & Fong, 2008) such that … neuropsychologists … will be able to visualize brain activation patterns related to specific tests.

Signs & symptoms vary widelyMay/may not be obvious signs

Post-concussion symptoms: subtle, unnoticed by patient, doctors, family members

Varied training of medical professionals who claim to "treat" concussions

Patient's reluctance to report symptoms

• Temporary confusion or amnesia in absence of loss of consciousness is more common

• LOC is not always predictive of recovery after mild TBI [Guskiewicz et al., 2003; Lovell et al., 1999]

• Linear - Example: A client falls to the ground and hits the back of his head. The falling motion propels the brain in a straight line downward.

• Rotational- Example: When a client falls, his head may strike an object as he is falling; this contact to the head can cause a rotational motion.

Percentage of Subjects Endorsing Symptoms

• Impaired attention -- vacant stare, delayed responses, inability to focus

• Slurred or incoherent speech• Gross incoordination• Disorientation• Emotional reactions out of proportion• Memory deficits• "Altered" consciousness

• Persistent headache• Dizziness/vertigo• Poor attention and concentration• Memory dysfunction• Nausea or vomiting• Fatigue easily• Irritability• Intolerance of bright lights• Intolerance of loud noises• Anxiety and/or depression• Sleep/Eating disturbances• Behavioral Changes• Poor academic performance

Later Signs of Concussion - Occuring from days to weeks

Methods & tools to detect concussion & make accurate return-to-play decisions are inadequate when used independently of each other

Traditional neurological exam & imaging (CT, MRI) are not consistently useful Lack of data on youngest age groups affected by concussions

Fiction:“A concussion is a minor head injury with no long-term effects.”FACT:

A concussion is a minor or mild brain injury. Symptoms of a concussion can last hours, days,

weeks, months or indefinitely. Long-term problems can include: memory loss,

poor concentration, anxiety, depression, & personality changes.

*

Fiction:“If there is no visible injury, everything is okay!”

FACT: Concussions often do not result in any obvious signs &

symptoms. Signs may be subtle & may not appear for hours or days

following injury.

Fiction:“Symptoms of a concussion will always clear up, usually within a few days.”FACT:• Most patients report significant recoverywithin a short timeframe of 7 to 10 days; however full recovery from a first time

concussion may take up to 45 days.Approximately 15-20% will experience symptoms lasting for weeks, months, or longer• Post-concussion syndrome (post-concussive signs & symptoms > 3

weeks duration) may develop, further delaying recovery

Fiction:“A normal CT (computed tomography) scan can rule out a concussion.”

FACT: CT scan only identifies structural damage A concussion is an alteration of the brain’s normal functioning Advanced neuroimaging techniques (e.g. fMRI, DTI)

Fiction :“All concussion grading scales are the same”

FACT: There are over 17 different concussion severity grading

scales Concussion severity should be graded on basis of presence

and overall duration of symptoms (i.e. after all symptoms have cleared) [Guskiewicz et al., 2004]

Focus attention on patient's recovery w/o too much emphasis on grading system.

Fiction:“The harder someone is hit, the worse the concussion.”

FACT: Any contact to head or body causing rapid head movement

can cause a concussion Several low impact hits over time might be more serious than

a single high force collision.

Fiction:“Helmets prevent concussions.”

FACT: Helmets are designed to prevent skull fracture & other serious head

injuries; they are not designed to prevent concussions. A properly fitted helmet may reduce risk or severity of a concussion.

Fiction:“A patient should be completely restricted from activity after a concussion.”FACT:

Current clinical recommendations: complete rest from physical & cognitive activities.

No evidence that cognitive activity following injury increases risk for further concussions or that complete restriction of all activity accelerates recovery.

Brain can benefit from appropriately-timed voluntary exercise [Griesbach et al., 2004; Majerske et al., 2008]

The FACTS about Concussion

A concussion is a brain injury All concussions are serious Concussions can occur without loss of consciousness Concussions can occur in any sport or activity Recognition & management of concussions when they first

occur can help prevent further injury or death, & possible long-term complications

Assesses abstract problem solving ability

f-MRT

Matrix

Reasoning

Assesses cognitive set shifting, cognitive processing speed, attention, sequencing, mental flexibility, and visual search

f-TMT

Trail

Making

Assesses object recognition and language production

f-PNT

Picture

Naming

Assesses long-term memory processingf-FMT

Face

Memory

Assesses short-term memory processing

f-VMT

Verbal

Memory

Assesses a broad range of executive and linguistic functions

f-VFT

Verbal

Fluency

How the fNCI Guides Treatment

Letter Fluency TaskNormal Subject

Letter Fluency TaskPatient with MTBI Normal Subject MTBI Patient

Hammeke, McCrea, et al, 2008

38 MTBI athletes and their matched controls were studied on a memory encoding task at Day 2 post injury and again at Day 30 post injury.

Matched Controls Memory Encoding

Day 2 Post Concussion Memory Encoding

Day 30 Post Concussion Memory Encoding

• Functional NCI – Notus NeuroCogs with Structural Read Included

• Cognitive Treatment• Motor Control, Symmetry, and balance treatment,

Optogait• Nutritional and Sleep Program• Psychology• Vestibular and Ocular Treatment• Body Work• Treatment for dizziness, headaches, nausea, and

other common physical symptoms of concussion

fNCI guides Treatment

Symptoms alone do not reveal areas of damage

● Visual search/spatial awareness regions of brain

● Executive/pain symptoms● Eye motor ● Vestibular - inner ear problems● Muscular or Joint related

fNCI targets therapies to address functional brain regions

● Visual search/tracking regions/data integration regions (S.C., Thalamus)o motor visual tracking and spatial awareness difficulties

Visual tracking exercises and sensory input exercises● Visual regions (Occipital)

o hyperactivated cortex causing fatigue and light sensitivity endurance exercises and ocular conditioning

● Executive Dysregulation (Frontal)o pain and executive function impairment comorbidity

destimulation integrated with calibrated visual exercises● Other Regions (Hippocampal, Brocas, SMA, etc)

o Memory, language, motor control, balance, and other impairments visual exercises integrated with appropriate functional

stimuli

fNCI guides overall treatment

• fNCI can detect injury and contour treatment

• Targeted treatments accelerate recovery

• Return to play/work more quickly and with confidence

• Players/Patients will feel less pressure to hide injury

• Players/Patients can provide evidence of recovery

• Players will feel protected knowing their health and information is more in their control

• CFX program gives ex-athletes/players of any age the same opportunities for rehab and improvement

• Players can get baselines and track their own brain function over the course of their career and life

Hospital

No structural read

2-3 tests administered

No Severity Scale included

No validity analysis

Limited report with general recommendations

Outside, disparate network of therapists

CFX

Structural Safety Read Included! Getting two scans for the price of one!

Comprehensive 7 test battery

Concussion Severity Scale from 0-6 included!

Full Validity analysis

fNCI Report integrated with full Neuropsychological Test Battery

Direct referral to in-house therapists fully trained in fNCI interpretion

fNCI conducted in-house, on premises for quality assurance, with same-day service in most cases!

• Dr. Bruce McIff offers:

– Structural MRI reads of other areas of the body:

• Cervical, soft tissue neck• Structural Brain• Joints (shoulder, wrist, knee, etc).• Pelvis, Lumbar, Thoracic

Concussion with CFX Treatment

Concussion Biomarkers

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1 Medial Prefrontal Hypoactivation - green2 Subcortical Hypoactivation - blue3 Visual System Hyperactivation - red4 Left Frontal Language Hypoactivation - yellow5 DLPFC Hyperactivation - purplel Hypoactivation - green2 Subcortical Hypoactivation - blue3 Visual System Hyperactivation - red4 Left Frontal Language Hypoactivation - yellow5 DLPFC Hyperactivation - not present in patient

Misdiagnoses???

•Dementia

•Multiple Sclerosis

•Schizophrenia

•Attention Deficit Disorders

•Other Psychiatric Disorders

Within Normal Limits: 0-1.5

Effort/Symptom Validity/Malingering

fNCI Provides Redundant Measures1.Objectively Measured Performance Criteria

•Response times •Response patterns•Accuracy rates

2.Observed Activation Patterns

Normal ActivationActivation

Indicative of Low Effort

Activation Indicative of Intentional Poor

Outcome

Expected normal pattern “default

network” (low effort)

Excessive activation associated with “response strategy”