Gerard A. Gioia

National Athletic Trainers' Association Position Statement: Management of Sport Concussion

OBJECTIVE To provide athletic trainers, physicians, and other health care professionals with best-practice guidelines for the management of sport-related concussions. BACKGROUND An estimated 3.8 million concussions occur each year in the United States as a result of sport and physical activity. Athletic trainers are commonly the first medical providers available onsite to identify and evaluate these injuries. RECOMMENDATIONS The recommendations for concussion management provided here are based on the most current research and divided into sections on education and prevention, documentation and legal aspects, evaluation and return to play, and other considerations.

Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Profiles of Everyday Executive Function in Acquired and Developmental Disorders

Executive function profiles were examined within and between several clinical disorders via the multidomain Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000). Parent ratings of children with Inattentive and Combined types of Attention-Deficit/Hyperactivity Disorder (ADHD-I, ADHD-C), Autistic Spectrum Disorders (ASD), moderate and severe Traumatic Brain Injury (TBI), and Reading Disabilities (RD) were compared with controls. Profile analysis revealed significant (p <.01) and substantial (? 2 >.10) differences in global elevations and in profile of scale elevations between diagnostic groups. ASD, ADHD-I and ADHD-C groups exhibited greater elevations across the BRIEF scales than did RD and Severe TBI groups, who were in turn more elevated than Moderate TBI and Control groups. The ADHD-C group was unique in its frequency and severity of inhibitory deficits, while the ASD group was distinguishable by its deficits in flexibility. Within diagnostic groups, relative risk for executive dysfunction was calculated with variability present in the frequency of clinically elevated scales. While the BRIEF captures executive profiles characteristic of specific disorders in the clinical setting, it is not diagnostic in its own right and is best used within the context of a broad based evaluation.

Ecological assessment of executive function in traumatic brain injury.

Executive dysfunction is a common outcome in children who have sustained traumatic brain injury (TBI). Appropriate assessment of these complex interrelated regulatory functions is critical to plan for the necessary interventions yet present a challenge to our traditional methodologies. Ecological validity has become an increasingly important focus in neuropsychological assessment with particular relevance for the executive functions, which coordinate ones cognitive and behavioral capacities with real-world demand situations. The Behavior Rating Inventory of Executive Function (BRIEF) was developed to capture the real-world behavioral manifestations of executive dysfunction. Its development and various forms of validity, including ecological validity, are described. Application of the BRIEFs methodology to the assessment of executive dysfunction in TBI is provided. We advocate a multilevel approach to understanding executive function outcome in TBI, including traditional test-based measures of executive function, real-world behavioral manifestation of executive dysfunction, and the environmental system factors that impact the child. In this model, ecologically valid assessment of executive dysfunction provides an important bridge toward understanding the impact of component-level (i.e., test-based) deficits on the childs everyday adaptive functioning, which can assist the definition of targets for intervention.

Confirmatory Factor Analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a Clinical Sample

Evidence for the validity of the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) based on internal structure was examined in a sample of children with mixed clinical diagnoses via maximum likelihood confirmatory factor analysis. Four alternative factor models of childrens executive function, based on current theories that posit a unidimensional versus fractionated model (Rabbitt, 1997; Shallice & Burgess, 1991), using the revised 9-scale BRIEF configuration that separates two components of the Monitor scale, were examined for model fit. A 3-factor structure best modeled the data when compared directly with 1-, 2-, and 4-factor models. The 3-factor model was defined by a Behavior Regulation factor consisting of the BRIEF Inhibit and Self-Monitor scales, an Emotional Regulation factor consisting of the Emotional Control and Shift scales, and a Metacognition factor composed of the Working Memory, Initiate, Plan/Organize, Organization of Materials, and Task-Monitor scales. The findings support a fractionated, multi-component view of executive function as measured by the BRIEF.

Neurocognitive status in long-term survivors of childhood CNS malignancies: a report from the Childhood Cancer Survivor Study.

To assess neurocognitive functioning in adult survivors of childhood Central Nervous System (CNS) malignancy, a large group of CNS malignancy survivors were compared to survivors of non-CNS malignancy and siblings without cancer on a self-report instrument (CCSS-NCQ) assessing four factors, Task Efficiency, Emotional Regulation, Organization and Memory. Additional multiple linear regressions were used to assess the contribution of demographic, illness, and treatment variables to reported neurocognitive functioning in CNS malignancy survivors and the relationship of reported neurocognitive functioning to socioeconomic indicators. Survivors of CNS malignancy reported significantly greater neurocognitive impairment on all CCSS-NCQ factors than non-CNS cancer survivors or siblings (p < .01). Within the CNS malignancy group, medical complications (hearing deficits, paralysis and cerebrovascular incidents) resulted in a greater likelihood of reported deficits on all CCSS-NCQ factors. Total or partial brain irradiation and ventriculoperitoneal (VP) shunt placement was associated with greater impairment on Task Efficiency and Memory. Female gender was associated with a greater likelihood of impaired scores on Task Efficiency and Emotional Regulation, while diagnosis before age 2 years resulted in less likelihood of reported impairment on the Memory factor. CNS malignancy survivors with more impaired CCSS-NCQ scores demonstrated significantly lower educational attainment (p < .01), less household income (p < .001), less full time employment (p < .001), and fewer marriages (p < .001). Survivors of childhood CNS malignancy were found to be at significant risk for neurocognitive impairment that continues to adulthood and is correlated with lower socioeconomic achievement.

School and the Concussed Youth: Recommendations for Concussion Education and Management

School learning and performance is arguably the critical centerpiece of child and adolescent development, and there can be significant temporary upset in cognitive processing after a mild traumatic brain injury, also called a concussion. This injury results in a cascade of neurochemical abnormalities, and, in the wake of this dysfunction, both physical and cognitive activities become sources of additional neurometabolic demand on the brain and may cause symptoms to reemerge or worsen. This article provides a foundation for postinjury management of cognitive activity, particularly in the school setting, including design and implementation of schoolwide concussion education and management programs.

Recommendations for the Use of Common Outcome Measures in Pediatric Traumatic Brain Injury Research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroups recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Which symptom assessments and approaches are uniquely appropriate for paediatric concussion

Objective: To (a) identify post-concussion symptom scales appropriate for children and adolescents in sports; (b) review evidence for reliability and validity; and (c) recommend future directions for scale development. Design: Quantitative and qualitative literature review of symptom rating scales appropriate for children and adolescents aged 5 to 22 years. Intervention: Literature identified via search of Medline, Ovid-Medline and PsycInfo databases; review of reference lists in identified articles; querying sports concussion specialists. 29 articles met study inclusion criteria. Results: 5 symptom scales examined in 11 studies for ages 5–12 years and in 25 studies for ages 13–22. 10 of 11 studies for 5–12-year-olds presented validity evidence for three scales; 7 studies provided reliability evidence for two scales; 7 studies used serial administrations but no reliable change metrics. Two scales included parent-reports and one included a teacher report. 24 of 25 studies for 13–22 year-olds presented validity evidence for five measures; seven studies provided reliability evidence for four measures with 18 studies including serial administrations and two examining Reliable Change. Conclusions: Psychometric evidence for symptom scales is stronger for adolescents than for younger children. Most scales provide evidence of concurrent validity, discriminating concussed and non-concussed groups. Few report reliability and evidence for validity is narrow. Two measures include parent/teacher reports. Few scales examine reliable change statistics, limiting interpretability of temporal changes. Future studies are needed to fully define symptom scale psychometric properties with the greatest need in younger student-athletes.

Improving identification and diagnosis of mild traumatic brain injury with evidence: psychometric support for the acute concussion evaluation.

ObjectivesA dearth of standardized assessment tools exists to properly assess and triage mild traumatic brain injury (mTBI) in primary care and acute care settings. This article presents evidence of appropriate psychometric properties for the Acute Concussion Evaluation (ACE), a new structured clinical interview. ParticipantsParent informants of 354 patients, aged 3 to 18 years, with suspected mTBI completed the ACE via telephone interview. MeasureAcute Concussion Evaluation. ResultsEvidence is presented for appropriate item-scale membership, internal consistency reliability as well as content, predictive, convergent/divergent, and construct validity of the ACE symptom checklist. ConclusionsOverall, the ACE symptom checklist exhibits reasonably strong psychometric properties as an initial assessment tool for mTBI.