Jamie E. Pardini

Measurement of Symptoms Following Sports-Related Concussion: Reliability and Normative Data for the Post-Concussion Scale

It is important to carefully evaluate self-reported symptoms in athletes with known or suspected concussions. This article presents data on the psychometric and clinical properties of a commonly used concussion symptom inventory-the Post-Concussion Scale. Normative and psychometric data are presented for large samples of young men (N = 1,391) and young women (N = 355). In addition, data gathered from a concussed sample of athletes (N = 260) seen within 5 days of injury are presented. These groups represent samples of both high school and collegiate athletes. Data from a subsample of 52 concussed athletes seen 3 times post-injury are presented to illustrate symptom reporting patterns during the initial recovery period. General guidelines for the clinical use of the scale are provided.

Recovery from sports concussion in high school and collegiate athletes

Introduction: Neuropsychological testing is a valuable tool in concussion diagnosis and management. ImPACT, a computerized neuropsychological testing program, consists of eight cognitive tasks and a 21-item symptom inventory. Method: ImPACT was used to examine the cognitive performance of 104 concussed athletes at baseline, 2, 7 and 14 days post-injury. Dependent measures included composite scores from the ImPACT computerized test battery, as well as a total symptom score from the Post-Concussion Symptom Scale. Results: Differences between baseline and day 2 post-injury scores were observed for all ImPACT composites (Verbal memory-VERM, visual memory-VISM, processing speed-PROC and reaction time-RT) as well as in total symptom score (SX). At day 7, concussed athletes continued to perform significantly poorer on VERM, VISM, RT and SX. At day 14, only VERM scores were significantly different from baseline. Conclusions: Cognitive performance deficits in concussed athletes may persist to 7 and even to 14 days in some cases. In addition to symptom status, the athletes post-concussion cognitive functioning should be considered when making return-to-play decisions.

FUNCTIONAL BRAIN ABNORMALITIES ARE RELATED TO CLINICAL RECOVERY AND TIME TO RETURN-TO-PLAY IN ATHLETES

OBJECTIVE The relationship between athlete reports of symptoms, neurophysiological activation, and neuropsychological functioning is investigated in a sample of high school athletes. METHODS All athletes were evaluated using functional magnetic resonance imaging (fMRI), a computer-based battery of neurocognitive tests, and a subjective symptom scale. Athletes were evaluated within approximately 1 week of injury and again after clinical recovery using all assessment modalities. RESULTS This study found that abnormal fMRI results during the first week of recovery predicted clinical recovery. As a group, athletes who demonstrated hyperactivation on fMRI scans at the time of their first fMRI scan demonstrated a more prolonged clinical recovery than athletes who did not demonstrate hyperactivation at the time of their first fMRI scan. CONCLUSION These results demonstrate the relationship between neurophysiological, neuropsychological, and subjective symptom data in a relatively large sample composed primarily of concussed high school athletes. fMRI represents an important evolving technology for the understanding of brain recovery after concussion and may help shape return-to-play guidelines in the future.

Neurocognitive and symptom predictors of recovery in high school athletes.

Objectives:The purpose of this study was to identify specific symptom and neuropsychological test patterns that might serve as prognostic indicators of recovery in concussed high school football players. The recently proposed simple versus complex concussion classification was examined and specific symptom clusters were identified. Design:Case-control study. Setting:High school football. Participants:Subjects were 108 recently concussed male high school football athletes between the ages of 13 and 19 (mean, 16.01) years. Assessment of Risk Factors:Participants were evaluated by utilizing the Immediate Postconcussion Assessment and Cognitive Testing computer-based neurocognitive test battery at before injury and within an average of 2.23 days of injury. All athletes were followed until they met criteria for clinical recovery. Main Outcome Measures:Symptom ratings and neurocognitive test performance. Results:Both neurocognitive test results and self-reported symptom data had prognostic value in determining time to clinical recovery. Self-reported cognitive decline, Immediate Postconcussion Assessment and Cognitive Testing reaction time, and migraine headache symptoms were associated with longer time to clinical recovery. Overall, these difficulties were predictive of concussions that were retrospectively classified as complex. Conclusions:Specific symptom clusters and neurocognitive test results may have predictive value to classifying and managing concussions.

A Revised Factor Structure for the Post-Concussion Symptom Scale Baseline and Postconcussion Factors

Background: Symptom reports play a critical role in the assessment and management of concussions. Symptoms are often conceptualized as factors comprising several related symptoms (eg, somatic factor = headache, nausea, vomiting). Previous research examining the factor structure of the 22-item Post-Concussion Symptom Scale (PCSS) has been limited to small samples and has not adequately evaluated factor loadings at both baseline and postconcussion for male and female athletes at the high school and collegiate levels. Purpose: To examine the factor structure of the 22-item PCSS in independent samples of high school and collegiate athletes reported at baseline and postconcussion, and to evaluate sex and age differences in the resulting baseline and postconcussion symptom factor scores. Study Design: Case series; Level of evidence, 4. Methods: Exploratory factor analytic (EFA) methods were applied to 2 separate samples of athletes who completed the PCSS at baseline (n = 30,455) and 1 to 7 days after a sport-related concussion (n = 1438). The baseline sample (mean ± standard deviation) was 15.74 ± 1.78 years, with a range of 13 to 22 years, and the postconcussion sample was 17.14 ± 2.25 years, with a range of 13 to 24 years. Results: A 4-factor solution accounting for 49.1% of the variance at baseline included a cognitive-sensory, sleep-arousal, vestibular-somatic, and affective factor structure. A 4-factor solution that included cognitive-fatigue-migraine, affective, somatic, and sleep was revealed for the postconcussion EFA. High school athletes reported higher baseline levels of the cognitive-sensory and vestibular-somatic symptom factors and lower levels of the sleep-arousal factor than college athletes. Female participants reported higher symptoms on all postconcussion factors than male participants. Conclusion: The current findings reveal different symptom factors at baseline and postinjury and several age and sex differences on the symptom factors. At postconcussion, symptoms aggregated into a global concussion factor including cognitive, fatigue, and migraine symptoms. Symptoms reported at baseline are not the same as those reported after injury. The presence of a global postconcussion symptom comprising the fatigue factor highlights the importance of physical and cognitive rest during the first week after a concussion. Although headache was the most commonly reported symptom, it was not the greatest contributor to the global postconcussion symptom factor.

Postconcussive symptoms are associated with compensatory cortical recruitment during a working memory task

BACKGROUND:The severity of sports-related concussion is often characterized by the number and severity of postconcussive symptoms (eg, headache, dizziness, difficulty concentrating). Although the level of postconcussive symptoms after injury is believed to index the severity of the neurological insult sustained, studies examining the relationship between symptom severity and neural functioning in concussed athletes remain rare. OBJECTIVE:This exploratory study examined the association between self-reported symptom severity and functional activation on a working memory task in a group of 16 recently concussed student athletes. METHODS:Functional magnetic resonance imaging was used to examine the relationship of symptom severity to brain activation during a working memory task in 16 concussed subjects. RESULTS:Findings indicated that symptom severity was associated with regionally specific hyperactivation during a working memory task, even though symptom severity was not significantly related to task accuracy. CONCLUSION:The results add to a growing body of literature that demonstrates that functional neuroimaging may have the potential to serve as a sensitive biomarker of the severity of concussion and mild traumatic brain injury.

New Developments in Sports Concussion Management

This chapter presents a discussion of the evolution of neuropsychological testing of concussed athletes. The advantages of computerized assessment are presented, with special emphasis on the ImPACT test battery, a widely used instrument in clinical research and practice.

Short-term neurocognitive outcomes following anterior temporal lobectomy

Changes in cognitive function are a well established risk of anterior temporal lobectomy (ATL). Deficits in verbal memory are a common postoperative finding, though a small proportion of patients may improve. Postoperative evaluation typically occurs after six to 12months. Patients may benefit from earlier evaluation to identify potential needs; however, the results of a formal neuropsychological assessment at an early postoperative stage are not described in the literature. We compared pre- and postoperative cognitive function for 28 right ATL and 23 left ATL patients using repeated measures ANOVA. Changes in cognitive function were compared to ILAE seizure outcome. The mean time to postoperative neuropsychological testing was 11.1weeks (SD=6.7weeks). There was a side×surgery interaction for the verbal tasks: immediate memory recall (F(1,33)=20.68, p<0.001), short delay recall (F(1,29)=4.99, p=0.03), long delay recall (F(1,33)=10.36, p=0.003), recognition (F(1,33)=5.69, p=0.02), and naming (F(1,37)=15.86, p<0.001). This indicated that the left ATL group had a significant decrement in verbal memory following surgery, while the right ATL group experienced a small but significant improvement. For the right ATL group, there was a positive correlation between ILAE outcome and improvement in immediate recall (r=-0.62, p=0.02) and long delay recall (r=-0.57, p=0.03). There was no similar finding for the left ATL group. This study demonstrates that short-interval follow-up is effective in elucidating postoperative cognitive changes. Right ATL was associated with improvement in verbal memory, while left ATL resulted in a decrement in performance. Improvement in the right ATL group was related to improved seizure outcome. Short-interval follow-up may lend itself to the identification of patients who could benefit from early intervention.