Prognosticating Protracted Recoveries from Sports Concussion: What are we Learning?

Transcription

1 Prognosticating Protracted Recoveries from Sports Concussion: What are we Learning? Associate Professor UPMC Department of Orthopaedic Surgery UPMC Department of Neurological Surgery Director UPMC Sports Medicine Concussion Program

2 Disclosure Statement Micky Collins, PhD is a Co-Founder and Board Member of ImPACT Applications, a computerized neurocognitive test battery designed to assess sports concussion and Mild Traumatic Brain Injury.

3 Objectives Present brief overview on recovery time and outcomes following sports-related mtbi Discuss evolving research on specific signs/symptoms and neurocognitive profiles that predict protracted recovery following sports mtbi Discuss the role of vestibular-ocular screening in the evaluation and clinical management of sports mtbi

4 Recovery from Sports Concussion: How long does it Take?

5 Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution Lovell et al McCrea et al Pro (NFL) Paper and Pencil NP 1 day 1 day 94 College SAC 1 Day 7 days McCrea et al College Paper and Pencil NP 5-7 days 7 days Echemendia College Paper and Pencil NP 3 days 3 days Guskiewicz et al Bleiberg et al Iverson et al McClincy et al Lovell, Collins et al 2008 Covassin et al 2011 Maugans et al College Balance BESS 64 College Computer NP 30 High School Computer NP 104 High School Computer NP 208 High School Computer NP 72 High School Computer NP 12 Ages Computer NP 3-5 Days 7 Days 3-7 days Did Not Evaluate 10 days 7 Days 14 days 7-10 Days 26 days 17 Days 21 days 7 Days 30 days 14 Days

6 Three-year prospective study in Western PA. 17 high school football teams 134 athletes with diagnosed concussion (6.2%) All athletes referred for evaluation at UPMC Recovery determined by Back to Baseline on computerized neurocognitive test scores and symptom inventory Determined by Reliable Change Index Scores-RCI s)

7 WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED N=134 High School Male Football Athletes All Athletes No Previous Concussions 1 or More Previous Concussions

8 Prognosticating Protracted Recovery Following Sports Concussion: What are we Learning?

9 Helps to set up clear communication regarding recovery expectations May help to alleviate some pressure on RTP issue Helps to provide individualized clinical management recommendations during sub-acute stage of recovery (e.g. need for academic accommodations/exertional recommendations, etc) Begins to create a risk profile for sports mtbi and may set stage to effectively research treatment and rehabilitation strategies. Because it is the next stage in our scientific understanding of this injury.

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12 Which 0n-Field Symptoms Predict Protracted Recovery? Lau B, Kontos A, Lovell MR, Collins MW. AJSM.Vol. 39(11): ; 2011

13 Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in High School Football Players? 176 Male HS Football Players (Mean Age = 16.2 years) Athletes had baseline computerized NP testing All followed until clinical recovery (Mean = 4.1 evaluations) Within RCI of baseline on ImPACT for neurocognitive/symptom scores 32% of sample required < 7 days until recovery (N =56) Rapid Recovery (Mean = 4.9 days) 39% of sample required 7-14 days until recovery (N = 68) 17% of sample required > 21 days until recovery (N = 31) Protracted Recovery (Mean = 33.2 days) MANOVA used to determine differences between rapid/> 3 week recovery ATC s documented on-field markers (e.g. LOC, Amnesia) and on-field Symptoms (e.g. headache, dizziness, etc) Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011

14 Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players **p<.01 On-Field Marker Chi 2 P Odds Ratio Posttraumatic Amnesia Retrograde Amnesia Confusion LOC On-Field Symptom Chi 2 P Odds Ratio 95% Confidence Interval 95% Confidence Interval Dizziness** Headache Sensitivity LT/Noise Visual Problems Fatigue Balance Problems Personality Change Vomiting The total sample was 107. Due to the normal difficulties with collecting on-field markers, there were varying degrees of missing data. The number of subjects who had each coded ranged from The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive. Lau, Kontos, Collins, Lovell, AJSM 2011

15 On-Field Symptom Summary Brief LOC (<30 sec) not predictive of sub-acute or protracted outcomes following sports-concussion (Collins et al 2003) Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery (Collins et al 2003) On-Field dizziness may be best predictor of protracted recovery Etiology of dizziness? Migraine variant? Central Vestibular Dysfunction? Peripheral Vestibular Dysfunction? Cervicogenic? Psychiatric?

16 Which Subacute Symptoms Predict Protracted Recovery? Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21

17 108 concussed high school football players Athletes had baseline computerized NP testing and were revaluated within 3 days of injury (Mean = 2.2 days) All followed until clinical recovery 43.5% of sample recovered < 10 days = Quick Mean = 5.9 Days 56.5% of sample required >10 days until recovery = Protracted Mean = 29.2 Days MANOVA conducted on which individual symptoms and symptom factors predicted quick versus protracted recovery Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21

18 Current Symptoms Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems (blurry or double vision)

19 FOGGY DIFF CONC VOMIT DIZZY NAUSEA HEADACHE SLOWNESS BALANCE LIGHT SENS NOISE SENS NUMBNESS Expressed as Effect Sizes (Cohen s D). Only includes symptoms with large (greater than.80) effect sizes. Sample is composed of 108 male HS football athletes.

20 Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual

21 Variables Classification Z-Score (Simple vs. Complex) Fogginess Cognitive 4.3* Difficulty Concentrating Cognitive 2.46 Vomit Migraine 2.391* Dizziness Migraine 2.09 Nausea Migraine 1.96 Headache Migraine 1.71 Slowness Cognitive 1.53 Balance Migraine 1.53 Light Sensitivity Migraine 1.52 Noise Sensitivity Migraine 1.52 Numbness Migraine 1.46 Trouble Sleeping Sleep 1.231* Visual Problems Migraine 0.97 Difficulty Remembering Cognitive 0.93 Sleeping Less Sleep.52 Drowsiness Cognitive 0.5 Fatigue Cognitive 0.48 Emotional Neuropsychiatric 0.37* Irritability Neuropsychiatric 0.3 Sadness Neuropsychiatric 0.09 Nervousness Neuropsychiatric Sleeping More Cognitive *Symptoms with the largest contributions to differences between quick and protracted recovery in each symptom factor.

22 Testing yields summary composite scores for: - Verbal Memory - Visual Memory - Reaction Time - Visual Motor Speed Computerized NP Summary Scores

23 NEUROCOGNITIVE PREDICTORS OF PROTRACTED RECOVERY (Greater than 10 days to Recovery) REACTION TIME VISUAL MEMORY Deficit in Reaction Time Best Predicts Protracted Recovery PROCESSING SPEED D=.838 (Large) p <.001 D=.663 (Medium) p<.001 D=.466 (Medium) VERBAL MEMORY p<.01 D=.221 (Small) p<.05 N = Effect Sizes compare quick recovery to protracted recovery groups. (Cohen s D)

24 The Role of Sub-Acute Migraine-Symptoms in Determining Outcomes Following Concussion Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; data in preparation for publication

25 Post-traumatic Migraine (PTM) Defined Post-traumatic Migraine Headache, nausea, AND sensitivity to light OR noise (International Headache Society Guidelines) Determined by utilizing PCSS at 1-7 days post-concussion Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

26 Study Overview 174 high school athletes with a concussion No prior hx of LD, moderate TBI, psychiatric disorder Athletes followed until recovery Computerized neurocognitive scores returned to baseline (w/in RCI) Symptom free and rest and exertion 97 athletes met Rapid or Protracted Criteria for Recovery: Rapid ( 7 days)= 61; Mean recovery = 5 days Protracted ( 21 days)= 36; Mean Recovery = 32 days Recovery studied for three groups No headache group Headache only group Post-traumatic migraine group (headache with nausea and/or light and noise sensitivity) Data Analysis Chi-square analysis with Odds Ratios for Recovery Time Groups Repeated measures ANOVAs for ImPACT scores across 3 time periods Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

27 How does PTM compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97) Variable Wald p Headache v. No Headache Odds Ratio 95% CI PTM v. Headache PTM v. No Headache Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..

28 ImPACT Visual Memory Raw Score PTM = Post Traumatic Migraine N = 97 HS Athletes with concussion Comparison of ImPACT Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ=.88, F= 4.24, p=.002, η 2 =.06)* *PTM significantly different than both groups at 1-7 and 8-14 days PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)

29 ImPACT Reaction Time Raw Score PTM = Post-Traumatic Migraine Comparison of Reaction Time scores for PTM, Headache, and No PTM or Headache groups (λ=.87, F= 4.96, p=.001, η 2 =.07) *PTM significantly different than both groups at 1-7 and 8-14 days PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification)

30 Conclusion It s more than just a headache : Athletes with migraine-type symptoms (headache with nausea and/or light-noise sensitivity) exhibit more protracted recovery than with athletes with headache only 81% of post-traumatic migraine group also reported dizziness (post-traumatic vestibular migraine?) Important to assess for quality and type of headache in athletes with concussion

31 Utilizing Sub-Acute Neurocognitive Test Data to Determine Prognosis

32 Computer-Based Neurocognitive Testing CURRENTLY AVAILABLE PROGRAMS Cogsport Headminders (CRI) ANAM CNS Vital Signs ImPACT

33 Sensitivity and Specificity of Computerized Neurocognitive Testing in Classifying Athletes with Concussion Schatz P, Pardini J, Lovell MR, Collins MW. Archives of Clinical Neuropsychology 2005:21; N = 138 controls/ concussed athletes Discriminate Function Analysis Statistical classification of Concussed (physician dx)/control subjects No Clinician Input Testing completed within 3 days post injury Positive Predictive Value (90%) (Probability that that a concussion is present when test is positive) Negative Predictive Value (82%) (Probability that a concussion is not present when test is negative)

34 Sensitivity and Specificity of Subacute Outcomes Variables in Classifying Short (<7 days) versus Protracted (>30 Days) Recovery from Sports Concussion Sensitivity Specificity Postitive Predictive Value Negative Predictive Value PCSS Symptom Total Score 40.81% 70.31% 62.5% 61.33% PCSS Symptom Clusters 46.91% 77.2% 63.9% 62.86% ImPACT Cognitive Composite Scores Combined Migraine Sub- Cluster and Neurocognitive Scores 53.20% 75.44% 64.10% 66.15% 65.22% 80.36% 73.17% 73.8% Lau B, Collins MW, Lovell M. American J Sports Med. 2011;39(6): Study examined ability of variables, at day 2 post-injury, to predict short (<7 day) versus protracted (>30 days) recovery in a sample (N = 108) male concussed football players.

35 Determination of Neurocognitive Cutoff Scores that Predict Protracted Recovery (at 2 days post injury) Lau B, Collins MW, Lovell MR Neurosurgery 2012;Feb 70(2):

36 108 concussed HS and Collegiate Athletes Athletes had baseline computerized NP testing All followed until clinical recovery 43.5% of sample recovered < 10 days = Quick Mean = 5.9 Days 56.5% of sample recovered >10 days = Protracted Mean = 33.0 Days Composite cutoff scores statistically calculated at 75%, 80%, and 85% sensitivity to predict protracted recovery (i.e., on average, 1 month or longer for clinical recovery) Lau B, Collins MW, Lovell MR. Neurosurgery 2012.

37 Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery 75% Sensitivitity 80% Sensitivity 85% Sensitiviity Neurocognitive Domain Cutoff Cutoff Cutoff Verbal Memory Visual Memory Processing Speed Reaction Time Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (Mean Recovery Time = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery 2012.

38 Iverson G. CJSM; 2008 Predicting Quick versus Protracted Recovery from Sports mtbi At three days post-injury, if athlete exhibit three or more RCI changes on ImPACT cognitive composite scores (relative to baseline), there is a 94.6% chance that recovery will require >10 days. Exhibiting a high symptom score did not improve classification accuracy over neurocognitive test scores in isolation. Athletes with prior history of concussion were not statistically more likely to have protracted recovery from concussion.

39 Other Recent Peer Reviewed Research Examining Neurocognitive Testing When computerized neurocognitive testing is utilized, athletes are less likely to return to play within a week compared to those in whom it was not utilized- 13.6% vs 32.9% (Meehan et al, AJSM, 2010).

40 Established (?) Constitutional Risk Factors For More Complicated Recovery Age - Field, Lovell, Collins et al. J of Pediatrics, Pellman, Lovell et al. Neurosurgery, 2006 Migraine History & Symptoms - Mihalik, Collins,Lovell et al, J Neurosurgery, 2006 Learning Disability - Collins, Lovell et al, JAMA, Kontos, Elbin, Collins, Data submitted for publication Repetitive Concussion? - Collins, Lovell et al, Neurosurgery, Iverson et al, CJSM, Moser et al, JCEN, 2011 Gender? - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, Covassin et al, CJSM, 2009

41 Summary Outcomes are highly variable Vestibular-related symptoms following injury predict more protracted recoveries Migraine-type symptoms (and potentially preexisting history of migraine) may place individuals at increased risk of injury and longer recovery Neurocognitive testing is valuable in determining prognosis and recovery in sports-related mtbi The mild injuries may become severe and the severe injuries may become mild

42 The Role of Vestibular-Ocular Screening in the Assessment and Rehabilitation of Sports Concussion

43 The UPMC Sports Concussion Program Department of Orthopaedic Surgery

44 The UPMC Sports Concussion Program Pediatric Practices ATC from Contracted Schools Emergency Departments Primary Care Physicians UPMC Concussion Program (Neuropsych) Parents /Schools Parents / School PM & R Vestibular / Physical Therapy Neuro Radiology Orthopaedic Surgery Neuro Surgery

45 Sports Concussion / mtbi Clinic Pediatric Practices ATC from Contracted Schools Emergency Departments PMR, Sports Med, Neurology, Pediatrics, Ortho, etc. Primary Care Physicians Parents /Schools Parents / School Neuropsych Neuro Radiology Vestibular / Physical Therapy Orthopaedic Surgery Neuro Surgery

46 UPMC Typical Evaluation 1.) Detailed Clinical Interview 2.) Vestibular Screening 3.) Computerized Neurocognitive Testing Same day patient feedback Severity of Injury? Prognosis for Recovery? Neuroimaging indicated? Level of Physical Exertion Allowed? Level of Cognitive Exertion Allowed? Academic Accommodations? Return to Play? Communication to ATC, Team Physician, Referring Physician, etc.

47 Vestibular-Ocular Screening Ocular-Motor: H-Test - Smooth Pursuits Vertical/Horizontal Saccades Any dizziness, blurriness, over/under shoots? Vestibular-Ocular: Vertical/Horizontal Gaze Stability (focus on stationary object while moving head up and down/side to side) Any observable nystagmus, provocative dizziness/blurriness, slowed movements? VOR Cancellation Ocular Convergence and Accommodation In high school/college aged athletes, near point < 6-8 cm Balance Examination Romberg, Compliant Foam-eyes open/eyes closed

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50 Vestibular Screening

51 Vestibular-Ocular Screening Expected Symptoms/Environmental Triggers Domain Symptoms Main Environmental Triggers Saccadic Eye Movements- Headache, Fatigue, Computer Work, Vertical and Horizontal Difficulty Reading, Watching concentrating Action Movies, Video Gaze Stability-Vertical and Horizontal Ocular Convergence (Convergence Insufficiency) VOR Cancellation Fogginess, Headache, Fatigue, Dizzy, Anxiety Headache (frontal), Fatigue, Irritability Nausea, Headache, Fogginess, Fatigue, Depersonalization, Anxiety Games Note Taking, Busy Environments, Hallways, Running, Gymnasiums, Busy Weightrooms Reading, Computer Work, Texting, Math and Chemistry, Car Rides, Supermarkets, Busy Environments, Wide Open Spaces Quote from Patients Its like my eyes are playing a slow game of ping pong It feels like I am outside myself, one step behind, and the world is in slow motion I feel like two fat men with two fat asses are sitting on my eyes While at the mall, I feel like I am looking out the side window of a highspeed car I just want to get out of there and it freaks me out

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54 Thank You Micky Collins, Ph.D (Direct) or (Secretary)

55 Interview

56 Utilizing Subacute Neurocognitive Test Data to Determine Prognosis

57 What is Sensitivity and Specificity of ImPACT Cognitive and Symptom Scores in Predicting Protracted Recovery? Lau B, Collins MW, Lovell M. American J Sports Med, 2011

58 What is Sensitivity/Specificity of ImPACT Cognitive and Symptom Scores in Predicting Protracted Recovery? 108 concussed high school football players (Mean Age=16.0) Athletes had baseline computerized neurocognitive testing and were revaluated within 3 days of injury (Mean = 2.2 days) All followed until clinical recovery 46% of sample recovered < 14 days = Quick Mean = 6.9 days 54% of sample recovered >14 days = Protracted Mean = 33.0 days T-Test conducted on differences of PCSS total score, Individual Symptom Clusters, and ImPACT Cognitive Composite Scores between Quick and Protracted Recovery Groups Discriminant Function Analysis conducted on examining Sensitivity and Specificity of variables in predicting group recovery Lau B, Collins MW, Lovell M. American J Sports Med, 2011

59 Current Symptoms Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems (blurry or double vision)

60 Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins et al. 2004) More emotional Sadness Nervousness Irritability Headaches Visual Problems Dizziness Noise/Light Sensitivity Nausea Attention Problems Memory dysfunction Fogginess Fatigue Cognitive slowing N=327, High School and University Athletes Within 7 Days of Concussion Difficulty falling asleep Sleeping less than usual

61 ImPACT yields composite scores for: - Verbal Memory - Visual Memory - Reaction Time - Visual Motor Speed Composite Scores

62 Variables Assessed at 2 Days Post Injury PCSS Total Score 22 items from ImPACT PCSS Four Symptom Clusters from Factor Analysis of PCSS Migraine Cluster Cognitive Cluster Neuropsychiatric Cluster Sleep Cluster Four Neurocognitive Composite Scores from ImPACT Verbal Memory Visual Memory Visual-Motor Speed (i.e. Processing Speed) Reaction Time First study to combine and quantify how well Computerized Neurocognitive testing and Symptom Profiles Predict Length of recovery following sports related concussion Lau B, Collins MW, Lovell M. American J Sports Med, 2011

63 Predicting Outcome Following Sports MTBI: Which Variables at 2 days post-injury differ b/w Groups? Variables Wilks Lambda F Value P Value Canonical Coefficient Migraine Cluster ImPACT Reaction Time ImPACT Visual Memory ImPACT Verbal Memory Neuropsychiatric Cluster Total PCSS score ImPACT Visual Motor Speed Cognitive Symptom Cluster Sleep Symptom Cluster Lau B, Collins MW, Lovell M. American J Sports Med, 2011

64 Predicting Outcomes Following Sports MTBI: Construct Definitions Sensitivity Specificity Ability of variables in discriminant function analysis (DFA) to identify athletes, at 2 days postinjury, who have protracted recovery when they actually have protracted recovery Ability of variables in discriminant function analysis (DFA) to accurately predict an athlete, at 2 days post-injury, who will NOT suffer from protracted recovery (i.e. will experience Quick recovery) Lau B, Collins MW, Lovell M. American J Sports Med, 2011

65 Predicting Outcomes Following Sports MTBI: Discriminant Function Analysis Sensitivity Specificity Postitive Predictive Value Negative Predictive Value PCSS Total Score 40.81% 70.31% 62.5% 61.33% PCSS Symptom Clusters 46.91% 77.2% 63.9% 62.86% ImPACT Neurocognitive Composite Scores Combined Migraine Cluster and Neurocognitive Scores 53.20% 75.44% 64.10% 66.15% 65.22% 80.36% 73.17% 73.8% Migraine Cluster = Headache, Dizzy, Nausea, Vision changes, Photo/phonophobia ImPACT = Reaction Time, Verbal Memory, Visual Memory Lau B, Collins MW, Lovell M. American J Sports Med, 2011

66 Predicting Outcomes Following Sports MTBI: Discriminant Function Analysis Sensitivity Specificity Postitive Predictive Value Negative Predictive Value PCSS Total Score 40.81% 70.31% 62.5% 61.33% PCSS Symptom Clusters 46.91% 77.2% 63.9% 62.86% Computerized Neurocognitive Composite Scores Combined Migraine Sub- Cluster and Neurocognitive Scores 53.20% 75.44% 64.10% 66.15% 65.22% 80.36% 73.17% 73.8% Lau B, Collins MW, Lovell M. American J Sports Med, 2011 Study examined ability of variables, at day 2 post-injury, to predict short (<7 day) versus protracted (>30 days) recovery in a sample (N = 108) male concussed football players.

67 Which Constitutional Risk Factors and Symptom Profiles Predict Post Concussion Syndrome?

68 On-Field Markers Summary Statistical Odds Ratios - Athletes with on-field retrograde amnesia were 10.0x more likely to have poor outcome at 3 days postconcussion - Athletes with on-field anterograde amnesia were 4.2x more likely to have poor outcome at 3 days postconcussion - Brief LOC not predictive of outcome Collins, Iverson, Lovell, et al.; Clinical J Sport Med, 2003

69 On-Field Predictors Summary Brief LOC (<30 sec) not predictive of subacute or protracted outcomes following sports-concussion Amnesia important for sub-acute presentation, but may not be as predictive of protracted recovery On-Field dizziness best predictor of protracted recovery and post concussion syndrome Etiology of dizziness? Migraine variant? Central Vestibular Dysfunction? Peripheral Vestibular Dysfunction? Cervicogenic? Psychiatric? Need clinical tools/physical examinations to better assess dizziness construct

70 Use of Computerized Neurocognitive Testing In High School Athletes (Meehan et al, 2011) 41.2% of US High Schools that employ at least 1 ATC utilized computerized neurocognitive testing during academic year (25.7% in year) 100% of schools utilizing testing reported that scores were utilized in making RTP decisions 86% of these schools performed baseline testing Athletes who underwent computerized NP tesing were less likely to be returned to play within 10 days of injury (38.5% vs 55.7%, p <.01) and were more likely to be returned to play by a physician (60.9% vs 45.6%, p <.01)

71 ImPACT Immediate Post-Concussion Assessment and Cognitive Testing Computerized Neurocognitive Testing Mark Lovell, PhD - UPMC Dept. of Orthopaedic Surgery Micky Collins, PhD - UPMC Dept. of Orthopaedic Surgery Joseph Maroon, MD - UPMC Dept. of Neurological Surgery

72 Established (?) Constitutional Risk Factors For More Complicated Recovery Age - Field, Lovell, Collins et al. J of Pediatrics, Pellman, Lovell et al. Neurosurgery, 2006 Migraine History & Symptoms - Mihalik, Collins,Lovell et al, J Neurosurgery, 2006 Learning Disability - Collins, Lovell et al, JAMA, Kontos, Elbin, Collins, Data submitted for publication Repetitive Concussion? - Collins, Lovell et al, Neurosurgery, Iverson et al, CJSM, Moser et al, JCEN, 2011 Gender? - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, Covassin et al, CJSM, 2009

73 ImPACT Computerized Neurocognitive Testing Demographic / Concussion History Questionnaire Concussion Symptom Scale 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc) 8 Neurocognitive Measures Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores Detailed Clinical Report Outlines Demographic, Symptom, Neurocognitive Data Internal baseline validity checks built into program Desktop and On-Line Versions Available Extensive normative data available from ages Over 100 peer-reviewed research articles/books/chapters, published since 2000 Extensive data published on reliability, validity, sensitivity/specificity of test

74 Comparison of Recovery for PTM, Headache, No Headache/PTM groups (χ2= 9.05, p=.009, n= 97)

75 Table 3: ROC Area Under Curve and P-values for Symptom Clusters and Neurocognitive Scores: Variable Area Under Curve P-Value *Migraine Symptom Cluster *Cognitive Symptom Cluster Visual Memory Processing Speed *Reaction Time Verbal Memory *Sleep Symptom Cluster *Neuropsychiatric Symptom Cluster *=Variables where increasing values indicate poorer performance =Variables where decreasing values indicate poorer performance Lau B, Collins MW, Lovell MR. Neurosurgery 2012.