Neuropsychological Evaluation of

Mild Traumatic Brain Injury (Concussion)Nathaniel W. Nelson, Ph.D., ABPP-CN1,2

1University of St. Thomas, Graduate School of Professional Psychology2Private Practice

Outline

1. Clinical Neuropsychology: Who We Are and What We Do

2. Assessment of Mild Traumatic Brain Injury (Concussion)

3. Natural History of Neuropsychological Recovery

4. Factors that May Extend Recovery

5. Treatment Considerations

Clinical Neuropsychology:Domains of Assessment

• Hundreds of standardized neuropsychological measures available to evaluate cognitive/psychological function

Basic Domains of Assessment:• Intellectual Function• Attention/concentration• Language• Visual-spatial Function• Motor Function• Executive Function• Learning/Memory (Visual and Auditory)• (Personality/Emotional)• (Effort/Motivation)

Holistic Approach to the Individual Patient

• Case Conceptualization in Clinical Neuropsychology• Incorporates Information from Multiple Aspects of

Patient Function:

• Cognitive

• Physical and Behavioral

• Psychological/Emotional

The Clinical Neuropsychologist:Thumbnail Sketch

Who are we?~80% doctoral-level Clinical/Counseling Psychologists with 2-year post-doc in Clinical Neuropsychology~80% work with adults, at least for part of their practice~42% institution-based, ~23% private practice, ~25% both institution/private practice, ~10% post-doctoral

What do we do?~85% clinical/administrative, 8% teaching/training, 7% research

When are we consulted (primary reasons for referral)?Determination of diagnosis (inpatient and outpatient)Treatment planning (inpatient and outpatient)Establish baseline of cognitive and/or psychological functioningEducational evaluationForensic evaluation

Where do our referrals come from (top 8 referral sources)?(1) Neurology(2) Psychiatry(3) Rehabilitation(4) Law (Attorney)(5) Neurosurgery(6) Internal Medicine(7) School System(8) Physiatry

Adapted from:

Sweet, Nelson, & Moberg (2006);

Sweet, Giuffre Meyer, Nelson, & Moberg (2011);

Sweet, Benson, Nelson, & Moberg (in preparation)

Top 5 Conditions Referred for Neuropsychological Evaluations*

Adapted from: Sweet, Nelson, & Moberg (2006); Sweet, Giuffre Meyer, Nelson, & Moberg (2011);

Sweet, Benson, Nelson, & Moberg (in preparation)

Rank 2005 2010 2015

1 Traumatic Brain Injury Traumatic Brain Injury Traumatic Brain Injury

2 ADHD ADHD ADHD

3 Learning Disorder Elderly dementias Elderly dementias

4 Elderly dementias Learning Disorder Seizure Disorder

5 Stroke Other medical/neurological

Other medical/neurological

*Includes respondents who evaluate patients across the full lifespan (i.e., pediatric and adult)

Mild TBI (Concussion) Most Frequent Level of Severity in Medical Settings

Incidence rates of TBI-related hospitalizations in the United States by category of severity (1980-1995).

Adapted from: Thurman, D., & Guerrero, J. (1999). Trends in hospitalization associated with traumatic brain injury. JAMA, 282, 954-957.

From: Sweet, Benson, Nelson, & Moberg (in preparation)

% Mild % Moderate % Severe

Work Setting

Institution 69 19 18

Private Practice 75 18 11

Institution/ Private Practice

67 21 16

Identity

Pediatric 67 19 20

Adult 71 19 15

Lifespan 69 20 15

TBI Severity Assessed

Frequency of TBI-Related Neuropsychological Evaluation (By Severity)

Outline

1. Clinical Neuropsychology: Who We Are and What We Do

2. Assessment of Mild Traumatic Brain Injury (Concussion)

3. Natural History of Neuropsychological Recovery

4. Factors that May Extend Recovery

5. Treatment Considerations

Assessing TBI Severity

• Glasgow Coma Scale (GCS; Teasdale & Jennet, 1974)

• 15-point scale that measures depth of coma according to post-injury responses to stimuli:

• Eye opening (1-4), • Verbal responsiveness (1-5)• Motor response (1-6)

• Composite score within 24-hours of resuscitation typically determines injury severity:

• Mild (13-15)• Moderate (9-12)• Severe (3-8)

Assessing TBI Severity

• TBI Severity Parameters:• Loss of Consciousness (LOC) and Duration• Alteration of Consciousness (AOC) and Duration• Post-traumatic Amnesia (PTA) and Duration• Evidence of brain injury disclosed on neuroimaging• Glasgow Coma Scale (GCS) Status

• “Measures of duration of impaired consciousness typically are better predictors of outcome than measures of depth of coma such as the GCS” (Dikmen, Machamer, & Temkin, 2009, p. 600).

Mild TBI (Concussion): Diagnosis From Acute-Injury Parameters

Note. *Indisputable evidence of positive brain MRI finding may result in assignment of mild ‘complicated’ TBI.

Adapted from: Corrigan et al. (2010); VA/DoD (2009); New Zealand Guidelines Group (2006).

Criteria Mild Moderate Severe

Structural imaging Normal* Normal or abnormal Normal or abnormal

Loss of Consciousness (LOC) 0 – 30 minutes >30 minutes and < 24

hours> 24 hours

Alteration of consciousness/mental state (AOC)

A moment up to 24 hours >24 hours. Severity based on other criteria.

>24 hours. Severity based on other criteria.

Post-traumatic amnesia (PTA) 0-1 day >1 and < 7 days > 7 days

Glasgow Coma Scale (best available score in first 24 hours)

13-15 9-12 <9

Outline

1. Clinical Neuropsychology: Who We Are and What We Do

2. Assessment of Mild Traumatic Brain Injury (Concussion)

3. Natural History of Neuropsychological Recovery

4. Factors that May Extend Recovery

5. Treatment Considerations

Cognitive Recovery by TBI Severity (One-Year Post-Injury)

<1 Hour 1-24 Hours 2-5 Days 6-13 Days 14-28 Days >29 Days0

0.5

1

1.5

2

2.5

Time from Injury to Follow Verbal Commands

Note. The figure depicts overall impairment in neuropsychological performance at one-year post injury by TBI severity (the amount of time after injury until victim could follow verbal commands). Results from Dikmen et al. (1995) as summarized by Larrabee (2012). Effect sizes represented as Cohen’s d with positive values representing greater impairment

From McCrea, M. (2001). Standardized mental status testing on the sideline after sport-related concussion. Journal of Athletic Training, 36, 274-279.

From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.

From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.

Mild Traumatic Brain Injury (Concussion):Favorable Course of Cognitive Recovery

Mild TBI Meta-Analyses:• Binder et al. (1997a, b)

• Beyond acute stage of recovery, small effect size on cognitive performance (d = -.12)

• Schretlen and Shapiro (2003)• Moderate effect size for cognitive impairment in acute stage of injury (d =

-.41)• Across all follow-up stages, small overall effect size for cognitive impairment

(d = -.24) • Full cognitive recovery typically attained after 1-3 months (d = -.08)

• Frencham et al. (2005), follow-up to Binder et al. (1997)• Small effect sizes across all stages post-injury• Effect tends toward zero at 3 months post-injury

• Belanger et al. (2005) • No residual neuropsychological impairment after 3 months post-injury (d

= .04). • Large effect sizes for clinic-based samples (d = .74) and litigants (d = .78)• Litigation associated with stable or worsening of cognitive functioning over

time.

• Iverson (2005, p. 311)• “Under most circumstances, we should anticipate good recovery following

an MTBI. Patients and athletes should be reassured.”

“The natural history of MTBI is reasonably well understood. For most people, regardless of age, the injury is self-limiting and follows a generally predictable course.”

“Permanent cognitive, psychological, or psychosocial problems due to the biological effects of this injury should be considered uncommon in trauma patients and rare in athletes” (p. 301).

From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.

Outline

1. Clinical Neuropsychology: Who We Are and What We Do

2. Assessment of Mild Traumatic Brain Injury (Concussion)

3. Natural History of Neuropsychological Recovery

4. Factors that May Extend Recovery

5. Treatment Considerations

Factors that May Extend Cognitive Recovery Following MTBI

• Premorbid/Co-Morbid Psychopathology

• Chronic Pain

• Misattribution, False Expectations, &

Self-Report Bias

• Secondary Gain & Symptom Exaggeration

Concussion and Premorbid/Co-morbid Psychopathology

• Premorbid psychopathology is prevalent among claimants with persisting cognitive difficulties post-MTBI

• Greiffenstein and Baker (2001)

• Co-morbid depression, anxiety, and coincident stressors may contribute to, or largely account for, late-stage ‘post-concussion’ symptoms

• Fann et al.(1995); Fenton et al. (1993); Polusny et al. (2011)

• Maladaptive personality traits (‘Axis II’ pathology) may also contribute to poor outcomes for select TBI samples, particularly among those with Axis I and Axis II conditions

• Hibbard et al. (2000); Evered et al. (2003)

Concussion and Premorbid/Co-morbid Psychopathology

Adapted from:

Nelson, N. W., Hoelzle, J. B., Doane, B. M., McGuire, K. A., Ferrier-Auerbach, A. G., Charlesworth, M. J., Lamberty, G. J., Polusny, M. A., Arbisi, P. A., & Sponheim, S. R. (in press). Neuropsychological outcomes of U.S. veterans with report of remote blast concussion and current psychopathology. Journal of the International Neuropsychological Society.

Control MTBI Only Axis I Only Co-Morbid Axis I/MTBI-0.2

-0.15-0.1

-0.050

0.050.1

0.150.2

0.250.3

Overall Cognitive Performance

Chronic Pain• Iverson & McCracken (1997)

• Significant minority (39%) of chronic pain patients (without history of head injury) reports ‘post-concussive symptoms’

• 42% reported at least one cognitive complaint, forgetfulness being the most common

• Paniak et al. (1998)• Injuries that commonly co-occur with MTBI (e.g.,

orthopedic; musculo-skeletal; whiplash-associated) “usually present a more pressing need for treatment than do MTBI sequelae” (p. 1020).

• Sheedy et al. (2006, 2009)• Pain symptoms identified acutely (i.e., in ER

settings) may for a minority of individuals predict chronic symptoms 3-months post-injury

Misattribution, False Expectations, & Self-Report Bias

• “Expectation as Etiology” • Mittenberg et al. (1992)

• “Diagnosis Threat”• Suhr & Gunstad (2002, 2005); Ozen &

Fernandez (2011)

• “Good Old Days Bias”• Gunstad & Suhr (1992); Iverson et al. (2010);

Lange, Iverson, & Rose (2010)

Secondary Gain, Disability, and Persisting Symptoms

• WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury (Carroll et al., 2004, p. 102):

“Although the evidence indicates good recovery for most adults sustaining MTBI, where symptoms and disability are persistent, compensation and litigation factors are important, and exploratory studies suggest that prior health, age and life stressors are also determinants of poorer outcome.”

Secondary Gain & Symptom Exaggeration: Trends in Malingering Research

Berry, D. T. R., & Nelson, N. W. (2010). DSM-5 and malingering: A modest proposal. Psychological Injury & Law, 3, 295-303.

Secondary Gain and Symptom Exaggeration

• Base rates of insufficient effort and malingering increase dramatically in workers’ compensation and other secondary gain contexts

• Mittenberg et al. (2002)• Survey of 388 U.S. neuropsychologists regarding 33,531

annual cases. Estimated rates of probable malingering:• Based on referral:

• Personal injury litigation = 29%• Disability = 30%• Criminal = 19%• Medical considerations = 8%

• Based on condition:• Mild head injury = 39%• Fibromyalgia/chronic fatigue = 35%• Chronic pain = 31%• Neurotoxicity = 27%• Electrical Injury = 22%

Outline

1. Clinical Neuropsychology: Who We Are and What We Do

2. Assessment of Mild Traumatic Brain Injury (Concussion)

3. Natural History of Neuropsychological Recovery

4. Factors that May Extend Recovery

5. Treatment Considerations

Treatment Considerations

• Psychoeducation; Early Reassurance of Recovery• Pre-discharge therapy session diminishes duration and

extent of post-injury symptoms

• Single session (SS) of education/reassurance within 3 weeks of injury is as effective as conventional ‘treatment-as-needed’ (TAN) with few symptoms reported 3 and 12 months post-injury

• Paniak et al. (1998, p. 1020): • “Education/reassurance should be provided,

preferably in both oral and written forms, in the acute care setting.”

Adapted from: Mittenberg et al. (1996); Paniak et al. (1998, 2000); WHO MTBI Task Force (Borg et al., 2004)

Treatment Considerations• Cognitive Behavioral Psychotherapy (CBT) and Other

Psychological Treatments• CBT may be particularly effective in treatment of

post-concussive symptoms

• Treated MTBI patients show diminished symptom complaints after three months; overall symptoms are comparable with matched control groups

• Limited evidence that multifaceted rehabilitation programs that include a psychotherapeutic element are of benefit in management of persisting symptoms

• Available research in treatment of MTBI is limited by small samples and lack of randomized trials. Further, more rigorous randomized control are trials needed.

Adapted from: Al Sayegh et al. (2010); Kashluba et al. (2004)

Treatment Considerations

• Hospital-Based Model for Clinical Management of MTBI (McCrea, 2008)• Multidisciplinary Approach

• Emergency Medical Providers• Physiatrist• Neuropsychologist• Nurse coordinator

• Based on the principle that effective intervention is ideally:• Early (i.e., within 1-5 days of injury)• Easily accessible and supportive• Educational (e.g., review common symptoms of time-limited duration)• Anchored in Empirical Literature• Not Intensive (in terms of sophisticated neurologic workup, neuroimaging,

or medical treatment)• Primary intervention is educational and psychological in most cases

• Follow-up sessions (as needed) • Continued reassurance and education• Address factors that may potentially interfere with recovery

Summary

1. Concussion diagnosis is made on the basis of acute-injury parameters LOC and duration; PTA and duration; GCS status; Neuroimaging findings

2. Concussion typically results in time-limited symptoms and impairmentsGreat majority attains rapid recovery in function that approaches baseline within days, weeks, to no more than a few months post-injury

3. Symptoms months/years after concussion (akin to “Post-Concussive Syndrome”) cannot be reliably linked with remote concussion

4. Non-concussion-related factors often account for persisting complaintsPremorbid/Co-morbid psychopathologyChronic PainMisattributionSecondary Gain/Exaggeration

5. Early interventions may prevent persisting symptomsPsychoeducation, ReassuranceCBT, other Supportive Counseling