Heather G. Belanger

Neuropsychological performance following a history of multiple self-reported concussions: a meta-analysis.

Debate continues about the long-term neuropsychological impact of multiple mild traumatic brain injuries (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of having a history of more than one self-reported MTBI (versus just one MTBI) across seven cognitive domains, as well as symptom complaints. The analysis was based on 8 studies, all conducted with athletes, involving 614 cases of multiple MTBI and 926 control cases of a single MTBI. The overall effect of multiple MTBI on neuropsychological functioning was minimal and not significant (d = 0.06). However, follow-up analyses revealed that multiple self-reported MTBI was associated with poorer performance on measures of delayed memory and executive functioning. The implications and limitations of these findings are discussed.

Symptom Complaints Following Combat-Related Traumatic Brain Injury: Relationship to Traumatic Brain Injury Severity and Posttraumatic Stress Disorder

Patients with a history of mild (n = 134) or moderate-to-severe (n = 91) TBI were asked to complete the Neurobehavioral Symptom Inventory (NSI) and the Posttraumatic Stress Disorder Checklist. Consistent with prior research, significantly more postconcussion symptoms were endorsed by the mild group. After controlling for age, time since injury, and mechanism of injury, TBI severity continued to be significantly related to postconcussion complaints on the NSI. However, after controlling for these same variables, along with posttraumatic stress disorder symptom severity, there no longer were differences between the TBI severity groups. That is, patients with mild TBI did not endorse significantly more complaints (adjusted mean = 22.4) than the moderate-to-severe group (adjusted mean = 21.8). These findings suggest that much of the symptom complaints in mildly injured patients may be due to emotional distress.

The Veterans Health Administration System of Care for Mild Traumatic Brain Injury: Costs, Benefits, and Controversies

The Veterans Health Administrations (VHAs) Polytrauma System of Care, developed in response to a new cohort of patients back from Iraq and Afghanistan, is described with particular focus on the assessment and treatment of mild traumatic brain injury (mild TBI). The development of systemwide TBI screening within the VHA has been an ambitious and historic undertaking. As with any population-wide screening tool, there are benefits and costs associated with it. The purpose of this article is to identify and discuss the strengths and weaknesses of the VHAs TBI clinical reminder and subsequent evaluation and treatment processes. Complicating factors such as increased media attention and other contextual factors are discussed.

Screening for a Remote History of Mild Traumatic Brain Injury: When a Good Idea Is Bad

Background:Both the Departments of Defense and Veterans Health Administration have developed and implemented screening procedures for identification of possible deployment-related traumatic brain injury (TBI). Objective:To review population-based screening procedures for TBI, particularly mild TBIs, and discuss potential harms/costs versus benefits of such TBI screening. Methods:The principles commonly used in population-based screening for various medical conditions are identified. These principles are applied to screening for TBI. The potential harms and costs are compared with potential benefits of screening for mild TBI. Results:The core conditions essential for beneficial medical screening—progressive disease, symptoms related to the identified disease, suitable tests or examinations for accurate diagnosis, and accepted and effective treatment—are not present within the context of TBI screening. Potential harms/costs outweigh any potential benefits of population-based screening for TBI. Conclusion:On the basis of generally accepted medical screening principles and assumptions, population screening for mild TBI is unnecessary at best and potentially harmful at worst. Because nonspecific, postconcussion-like symptoms can be effectively treated in a symptom-specific manner, tying them to concussion through a screening and evaluation process is wasteful and potentially harmful.

Subconcussive blows to the head: a formative review of short-term clinical outcomes

Background:Given questions about “lower thresholds” for concussion, as well as possible effects of repetitive concussion and chronic traumatic encephalopathy (CTE), and associated controversy, there is increasing interest in “subconcussive” blows and their potential significance. Objective:A formative review with critical examination of the developing literature on subconcussive blows in athletes with an emphasis on clinical outcomes. Methods:Studies of biomechanical, performance and/or symptom-based, and neuroimaging data were identified via PubMed search and critically reviewed. Five studies of symptom reporting/performance and 4 studies of neuroimaging were included. Results:The relation between biomechanical parameters and diagnosed concussion is not straightforward (ie, it is not the case that greater and more force leads to more severe injury or cognitive/behavioral sequelae). Neuropsychological studies of subconcussive blows within a single athletic season have failed to demonstrate any strong and consistent relations between number and severity of subconcussive events and cognitive change. Recent studies using neuroimaging have demonstrated a potential cumulative effect of subconcussive blows, at least in a subset of individuals. Conclusion:Human studies of the neurological/neuropsychological impact of subconcussive blows are currently quite limited. Subconcussive blows, in the short-term, have not been shown to cause significant clinical effects. To date, findings suggest that any effect of subconcussive blows is likely to be small or nonexistent, perhaps evident in a subset of individuals on select measures, and maybe even beneficial in some cases. Longer-term prospective studies are needed to determine if there is a cumulative dose effect.

An exploration of diagnosis threat and group identification following concussion injury.

Cognitive performance can be impacted by many non-neurological factors, including preexisting expectations. The phenomenon of stereotype threat, or reduced cognitive performance due to preexisting beliefs, can apply to individuals following neurological injury (i.e., ‘‘diagnosis threat’’). We examined the effect of diagnosis threat on cognitive performance and symptom reporting following concussions while accounting for group identification (i.e., extent to which one’s identity is tied to being concussed). We also examined gender stereotype threat (i.e., women and math ability) to understand how these two related threat effects compare. Participants with a history of concussion were randomly assigned to one of three instructional sets emphasizing concussion history or gender, or neutral instructions. Individuals without a history of concussion served as a comparison group. Results revealed an effect of diagnosis threat on cognitive performance after group identification was taken into account, but only in male participants. In contrast, an underlying gender stereotype threat was observed in females across conditions, which was counteracted in the gender stereotype condition (i.e., stereotype reactance effect) due to the type of threat cues used. Also, controls exhibited greater symptom reporting than individuals with a concussion. Our findings highlight the importance of considering non-neurological factors impacting cognitive performance.

Pilot of a novel intervention for postconcussive symptoms in active duty, veterans, and civilians.

PURPOSE/OBJECTIVE The authors present a study aimed at pilot testing a novel delivery method, namely a computer intervention, for postconcussive symptom reduction in active duty, veteran, and civilian patients with acute and chronic complaints. Following a concussion/mild traumatic brain injury (MTBI), most individuals recover completely, but a significant proportion report postconcussive symptoms months to years following the injury. Psychoeducational intervention has shown to be effective in reducing postconcussive symptoms in studies done with acute civilian samples, but the efficacy of psychoeducational interventions with individuals who served in combat or have chronic complaints remains unclear. RESEARCH METHOD/DESIGN Twenty-five active duty, veteran, and civilian participants took part in this study. At baseline, each participant completed a self-run psychoeducational computer-based treatment. Participants were reassessed 1-month postintervention via phone to evaluate postconconcussive symptom severity. RESULTS Participants reported significantly fewer postconcussive symptoms at follow-up than baseline (d = .99). Intervention satisfaction was reported, with feedback related to ease of use and quality. CONCLUSIONS/IMPLICATIONS Extending previous studies, current findings demonstrated that psychoeducational intervention following MTBI was associated with postconcussive symptom complaint reduction in both acute and chronic patients. These data also confirm the feasibility of using computerized psychoeducation and speak to the importance of providing education to both acute and chronic patients across settings. Feedback from participants was generally positive. Further investigation with a control group is warranted.

Assessing visuoconstructional performance in AD, MCI and normal elderly using the Beery Visual-Motor Integration Test.

This study evaluated the Beery Visual-Motor Integration Test (VMI) as a measure of construction ability in Alzheimer’s disease (AD) and mild cognitive impairment (MCI). Construction deficits are an early sign of Alzheimer’s disease. Commonly used tests of construction abilities are complex, often intimidating to impaired elders, and lack a range of items. The VMI has items ranging from very easy to difficult, allowing even impaired patients to enter task set, and elderly norms are available. It has not yet been validated for use in diagnosis of AD or MCI. Two patients groups (n =43 MCI and 40 AD) recruited from a memory clinic and a non-demented control group (n =43) recruited from the community were administered a battery of neuropsychological measures including the VMI. Results revealed that the VMI is useful for discriminating AD from MCI. Qualitative errors produced on the VMI provide additional information beyond the standard score about the patient’s cognitive status.

Mild Traumatic Brain Injury: Neuropsychological Causality Modelling

This chapter has focused on group data regarding outcomes following mTBI. However, in both the clinical and the medicallegal context, it is not the group but rather the individual who is the focus of interest. The question is no longer “What factors influence outcome following mTBI?” but rather “What is causing the symptoms or problems in this particular case?” The clinical arena can accommodate an ambiguous interactive systemic model of causality, but a legal arena is seeking to assign definitive responsibility. Also, in the individual case, it is often very difficult, if not impossible, to attribute mildly abnormal findings such as slightly more proactive memory interference than normal, mild balance difficulties, occasional visual imperceptions, headaches, dizziness, fatigue, and memory complaints to a particular etiology. Such a pattern of symptoms could represent (1) brain dysfunction, (2) a normal population variant, (3) pre-existing mental health problems (e.g., depression and anxiety), (4) pre-existing or coexisting medical problems (e.g., chronic pain syndrome, multiple sclerosis, hypertension, acquired immunodeficiency syndrome, alcohol-abuse-related complications), (5) inadequate patient effort on examination or outright malingering, or (6) a combination of these factors. Furthering the difficulty in determining etiological factors is weighing the degree to which pre-existing poor coping skills, selfbeliefs/ expectations, poor social support, medical iatrogenesis, or litigationbased iatrogenesis might amplify and extend residual post-mTBI problems. A conservative but limited approach for the health care provider might lie in time-tested, clinically validated diagnostic evaluations, a careful history of preinjury and postinjury symptoms and functioning, and a reliance on the medical linear model of causality. However, an increasingly used approach relies on the examination of multiple potential predisposing factors, causative agents, and perpetuating factors that interactively influence each other. Causality determination requires (1) examination of all relevant etiological events or factors, (2) investigation of the initial clinical presentation as being more or less consistent with those potential causative agents, (3) tracking ongoing or emerging symptoms as being consistent with the medical literature regarding potential causative agents and not consistent with other potential etiological factors, and (4) examination of findings from diagnostic procedures as being consistent with the clinical history, the nature and course of symptoms, and suspected explanatory causative factors. Only if a chronologically consistent and clinically logical pattern of results emerges after an alleged causal event can findings be attributed to it.

The Key Behaviors Change Inventory and executive functioning in an elderly clinic sample.

The Key Behaviors Change Inventory (KBCI) was developed to assess executive, behavioral, and emotional functioning following brain insults and to track the course of recovery. The purpose of this study was to investigate, in an elderly memory disorder clinic sample, the convergent and discriminant validity of the KBCI by examining the relationships between various measures of executive functioning and the KBCI scales that theoretically relate to executive functions. The KBCI was administered to the caregivers of 97 consecutive patients who came to a memory disorders clinic seeking services. The KBCI scales of Inattention, Apathy, Unawareness of Problems, and Communication Problems were significantly correlated with cognitive measures of executive functioning but not with measures of memory, visuospatial abilities or global cognitive functioning. In contrast, KBCI scales of Interpersonal Difficulties, Somatic Difficulties, and Emotional Adjustment were not related to any cognitive measures, either executive or nonexecutive. Contrary to predicted findings, the Impulsivity Scale was not associated with cognitive measures of executive functioning. This lack of relationship most likely reflects the failure to include executive measures of orbitofrontal functioning in this study. Results provide convergent and discriminant validity support for the KBCI. The KBCI may be a useful tool for assessing and tracking the executive, behavioral, and emotional sequelae of neurologic disorders.