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
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.
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
Copyright © 2011
Recovery
from Sports
Concussion:
How long
does it Take?
Copyright © 2011
Authors
Sample
Size
Population
Tests Utilized
Total Days Cognitive
Resolution
Total Days Symptom
Resolution
Lovell et al.
2005
95
Pro (NFL)
Paper and Pencil NP
1 day
1 day
McCrea et al.
2003
94
College
SAC
1 Day
7 days
McCrea et al.
2003
94
College
Paper and
Pencil NP
5-7 days
7 days
Echemendia
2001
29
College
Paper and Pencil NP
3 days
3 days
Guskiewicz et al.
2003
94
College
Balance
BESS
3-5 Days
7 Days
Bleiberg et al.
2005
64
College
Computer
NP
3-7 days
Did Not
Evaluate
Iverson et al.
2006
30
High School
Computer
NP
10 days
7 Days
McClincy et al.
2006
104
High School
Computer
NP
14 days
7-10 Days
Lovell, Collins et al
2008
208
High School
Computer
NP
26 days
17 Days
Covassin et al
2011
72
High School
Computer
NP
21 days
7 Days
Maugans et al
2011
12
Ages 11-15
Computer
NP
30 days
14 Days
Copyright © 2011
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)
Copyright © 2011
WEEK 1
100
90
80
70
60
50
40
30
20
10
0
WEEK 2
WEEK 3
WEEK 4
WEEK 5
80%
RECOVERED
60%
RECOVERED
N=134 High School
Male Football Athletes
40%
RECOVERED
1
3
5
All Athletes
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
No Previous Concussions
1 or More Previous Concussions
Prognosticating
Protracted Recovery
Following Sports
Concussion:
What are we
Learning?
Copyright © 2011
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….
Copyright © 2011
Show Video
Copyright © 2011
Which 0n-Field
Symptoms Predict
Protracted
Recovery?
Lau B, Kontos A, Lovell MR, Collins MW.
AJSM.Vol. 39(11):2311-18; 2011
Copyright © 2011
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
Which On-Field Markers/Symptoms Predict 3 or More Week
Recovery from MTBI In High School Football Players **p<.01
On-Field Marker
Chi2
P
Odds
Ratio
95% Confidence
Interval
Posttraumatic Amnesia
1.29
0.257
1.721
0.67-4.42
Retrograde Amnesia
.120
0.729
1.179
0.46-3.00
Confusion
.114
0.736
1.164
0.48-2.82
LOC
2.73
0.100
0.284
0.06-1.37
On-Field Symptom
Chi2
P
Odds
Ratio
95% Confidence
Interval
Dizziness**
6.97
0.008
6.422
1.39-29.7
Headache
0.64
0.43
2.422
0.26-22.4
Sensitivity LT/Noise
1.19
0.28
1.580
0.70-3.63
Visual Problems
0.62
0.43
1.400
0.61-3.22
Fatigue
0.04
0.85
1.080
0.48-2.47
Balance Problems
0.28
0.59
0.800
0.35-1.83
Personality Change
0.86
0.35
0.630
.023-1.69
Vomiting
0.68
0.100
0.600
0.18-2.04
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 92-98. The N column represents the number of subjects
for whom data were available for each category. Markers of injury are not mutually exclusive.
Copyright © 2011
Lau, Kontos, Collins, Lovell , AJSM 2011
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?
Copyright © 2011
Which Subacute
Symptoms
Predict Protracted
Recovery?
Lau B, Lovell MR, Collins MW; Pardini J;
CJSM 2009 (3):216-21
Copyright © 2011
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
Copyright © 2011
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)
Copyright © 2011
FOGGY
NAUSEA
LIGHT SENS
DIFF CONC
HEADACHE
NOISE SENS
VOMIT
SLOWNESS
NUMBNESS
DIZZY
BALANCE
2
1.5
1
0.5
0
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.
Copyright © 2011
Factor Analysis,
Post-Concussion
Symptom Scale
(Pardini, Lovell, Collins
et al. 2004)
•
•
•
•
•
•
•
•
•
Headaches
Visual Problems
Dizziness
Noise/Light Sensitivity
Nausea
N=327, High School
and University
Athletes Within
7 Days of Concussion
Copyright © 2011
More emotional
Sadness
Nervousness
Irritability
•
•
•
•
•
Attention Problems
Memory dysfunction
“Fogginess”
Fatigue
Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
Variables
Fogginess
Difficulty Concentrating
Vomit
Dizziness
Nausea
Headache
Slowness
Balance
Light Sensitivity
Noise Sensitivity
Numbness
Classification
Cognitive
Cognitive
Migraine
Migraine
Migraine
Migraine
Cognitive
Migraine
Migraine
Migraine
Migraine
Trouble Sleeping
Visual Problems
Difficulty Remembering
Sleeping Less
Drowsiness
Fatigue
Emotional
Sleep
Migraine
Cognitive
Sleep
Cognitive
Cognitive
Neuropsychiatric
Irritability
Sadness
Nervousness
Neuropsychiatric
Neuropsychiatric
Neuropsychiatric
Sleeping More
Cognitive
Z-Score (Simple vs. Complex)
4.3*
2.46
2.391*
2.09
1.96
1.71
1.53
1.53
1.52
1.52
1.46
1.231*
0.97
0.93
.52
0.5
0.48
0.37*
0.3
0.09
-0.03
-0.05
*Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.
Copyright © 2011
Testing yields summary
composite scores for:
- Verbal Memory
- Visual Memory
- Reaction Time
- Visual Motor Speed
Computerized NP
Summary Scores
Copyright © 2011
NEUROCOGNITIVE PREDICTORS OF PROTRACTED
RECOVERY (Greater than 10 days to Recovery)
REACTION TIME
PROCESSING SPEED
VISUAL MEMORY
VERBAL MEMORY
0
Deficit in
Reaction
Time
Best
Predicts
Protracted
Recovery
D=.221
(Small)
-0.2
D=.466
(Medium)
p<.05
-0.4
-0.6
D=.663
(Medium)
D=.838
(Large)
p<.01
p<.001
-0.8
p <.001
-1
Effect Sizes compare quick recovery to protracted
recovery groups. (Cohen’s D)
Copyright © 2011
N = 108
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
Copyright © 2011
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
Copyright © 2011
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
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
–
–
Copyright © 2011
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..
How does PTM compare to No Headache and Headache groups in
predicting Protracted (>21 days) Recovery from Sports
Concussion? (N= 97)
Variable
Wald
p
Odds
Ratio
Headache v. No
Headache
2.20
.14
2.83
0.72-11.20
PTM v. Headache
3.93
.04
2.57
1.10-6.54
PTM v. No
Headache
7.60
.006
7.29
1.80-29.91
95% CI
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
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, η2 = .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)
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, η2= .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)
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
Copyright © 2011
Utilizing Sub-Acute
Neurocognitive Test
Data to Determine
Prognosis
Copyright © 2011
Computer-Based
Neurocognitive Testing
CURRENTLY AVAILABLE PROGRAMS
Cogsport
Headminders (CRI)
ANAM
CNS Vital Signs
ImPACT
Copyright © 2011
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;91-99.
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)
Copyright © 2011
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
53.20%
75.44%
64.10%
66.15%
Combined Migraine SubCluster and Neurocognitive
Scores
65.22%
80.36%
73.17%
73.8%
Lau B, Collins MW, Lovell M. American J Sports Med. 2011;39(6):1209-16.
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.
Copyright © 2011
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):371-79.
Copyright © 2011
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.
Copyright © 2011
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
66.5
64.5
60.5
Visual Memory
48
46
44.5
Processing Speed
24.5
23.5
22.5
Reaction Time
0.72
0.78
0.86
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.
Copyright © 2011
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.
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 utilized13.6% vs 32.9% (Meehan et al, AJSM, 2010).
Copyright © 2011
Established (?) Constitutional Risk Factors
For More Complicated Recovery
Age
-
Field, Lovell, Collins et al. J of Pediatrics, 2003
Pellman, Lovell et al. Neurosurgery, 2006
Migraine History &
Symptoms
-
Mihalik, Collins,Lovell et al, J Neurosurgery, 2006
Learning Disability
-
Collins, Lovell et al, JAMA, 1999
Kontos, Elbin, Collins, Data submitted for publication
Repetitive
Concussion?
-
Collins, Lovell et al, Neurosurgery, 2004
Iverson et al, CJSM, 2004
Moser et al, JCEN, 2011
Gender?
-
Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009
Covassin et al, CJSM, 2009
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
Copyright © 2011
The Role of
Vestibular-Ocular
Screening in the
Assessment and
Rehabilitation of
Sports Concussion
Copyright © 2011
The UPMC Sports Concussion Program
Department of Orthopaedic Surgery
Copyright © 2011
The UPMC Sports Concussion Program
ATC from
Contracted
Schools
Pediatric
Practices
Emergency
Departments
Primary Care
Physicians
UPMC
Concussion
Program
(Neuropsych)
Parents
Parents /
/Schools
School
Copyright © 2011
PM & R
Vestibular /
Physical
Therapy
Neuro
Radiology
Orthopaedic
Surgery
Neuro
Surgery
Sports Concussion / mTBI Clinic
ATC from
Contracted
Schools
Pediatric
Practices
Emergency
Departments
Primary Care
Physicians
PMR,
Sports Med,
Neurology,
Pediatrics,
Ortho, etc.
Parents
Parents /
/Schools
School
Copyright © 2011
Neuropsych
Neuro
Radiology
Vestibular /
Physical
Therapy
Orthopaedic
Surgery
Neuro
Surgery
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.
Copyright © 2011
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
Copyright © 2011
Injury
Copyright © 2011
Copyright © 2011
Vestibular Screening
Copyright © 2011
Vestibular-Ocular Screening
Expected Symptoms/Environmental Triggers
Domain
Symptoms
Main Environmental
Triggers
Saccadic Eye MovementsHeadache, Fatigue,
Computer Work,
Vertical and Horizontal
Difficulty
Reading, Watching
concentrating
Action Movies, Video
Games
Note Taking, Busy
Gaze Stability-Vertical and Fogginess, Headache,
Horizontal
Fatigue, Dizzy, Anxiety Environments, Hallways,
Running, Gymnasiums,
Busy Weightrooms
Ocular Convergence
Headache (frontal), Reading, Computer Work,
Texting, Math and
(Convergence Insufficiency) Fatigue, Irritability
Chemistry,
VOR Cancellation
Nausea, Headache,
Car Rides,
Fogginess, Fatigue,
Supermarkets, Busy
Depersonalization,
Environments, Wide
Anxiety
Open Spaces
Copyright © 2011
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”
Copyright © 2011
Copyright © 2011
Thank You
Micky Collins, Ph.D.
[email protected]
412-432-3668 (Direct) or 412-432-3681 (Secretary)
Copyright © 2011
Interview
Copyright © 2011
Utilizing Subacute
Neurocognitive Test
Data to Determine
Prognosis
Copyright © 2011
• 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
Copyright © 2011
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
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)
Factor Analysis,
Post-Concussion
Symptom Scale
(Pardini, Lovell, Collins
et al. 2004)
•
•
•
•
•
•
•
•
•
Headaches
Visual Problems
Dizziness
Noise/Light Sensitivity
Nausea
N=327, High School
and University
Athletes Within
7 Days of Concussion
More emotional
Sadness
Nervousness
Irritability
•
•
•
•
•
Attention Problems
Memory dysfunction
“Fogginess”
Fatigue
Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
ImPACT yields
composite scores for:
- Verbal Memory
- Visual Memory
- Reaction Time
- Visual Motor Speed
Composite Scores
Copyright © 2011
Variables Assessed at 2 Days Post Injury
PCSS Total Score
Four Symptom
Four Neurocognitive
Clusters from Factor Composite Scores
Analysis of PCSS
from ImPACT
22 items from
ImPACT PCSS
Migraine Cluster
Verbal Memory
Cognitive Cluster
Visual Memory
Neuropsychiatric
Cluster
Visual-Motor Speed
Sleep Cluster
Reaction Time
(i.e. Processing Speed)
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
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
.828
6.774
.012
.990
ImPACT Reaction Time
.807
4.233
.042
.682
ImPACT Visual Memory
.821
5.874
.017
.654
ImPACT Verbal Memory
.806
4.070
.047
.470
Neuropsychiatric Cluster
.792
2.420
.123
.431
Total PCSS score
.785
2.160
.200
.425
ImPACT Visual Motor Speed
.785
1.622
.206
.416
Cognitive Symptom Cluster
.776
0.478
.491
.253
Sleep Symptom Cluster
.780
0.942
.334
.242
Lau B, Collins MW, Lovell M. American J Sports Med, 2011
Copyright © 2011
Predicting Outcomes Following Sports
MTBI: Construct Definitions
Sensitivity
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
Specificity
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
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
53.20% 75.44%
64.10%
66.15%
Combined Migraine Cluster
and Neurocognitive Scores
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
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
53.20%
75.44%
64.10%
66.15%
Combined Migraine SubCluster and Neurocognitive
Scores
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.
Copyright © 2011
Which
Constitutional
Risk Factors and
Symptom Profiles
Predict Post
Concussion
Syndrome?
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
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
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 2009-2010
academic year (25.7% in 2008-2009 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)
Copyright © 2011
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
Copyright © 2011
Established (?) Constitutional Risk Factors
For More Complicated Recovery
Age
-
Field, Lovell, Collins et al. J of Pediatrics, 2003
Pellman, Lovell et al. Neurosurgery, 2006
Migraine History &
Symptoms
-
Mihalik, Collins,Lovell et al, J Neurosurgery, 2006
Learning Disability
-
Collins, Lovell et al, JAMA, 1999
Kontos, Elbin, Collins, Data submitted for publication
Repetitive
Concussion?
-
Collins, Lovell et al, Neurosurgery, 2004
Iverson et al, CJSM, 2004
Moser et al, JCEN, 2011
Gender?
-
Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009
Covassin et al, CJSM, 2009
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 11-60
Over 100 peer-reviewed research articles/books/chapters, published since
2000

Copyright © 2011
Extensive data published on reliability, validity, sensitivity/specificity of test
Comparison of Recovery for PTM, Headache, No Headache/PTM groups
(χ2= 9.05, p= .009, n= 97)
Table 3:
ROC Area Under Curve and P-values for
Symptom Clusters and Neurocognitive Scores:
Variable
*Migraine Symptom Cluster
*Cognitive Symptom Cluster
†Visual Memory
†Processing Speed
*Reaction Time
†Verbal Memory
*Sleep Symptom Cluster
*Neuropsychiatric Symptom Cluster
Area Under Curve
0.66
0.61
0.66
0.63
0.63
0.45
0.55
0.53
P-Value
0.01
0.04
0.01
0.02
0.02
0.39
0.41
0.61
*=Variables where increasing values indicate poorer performance
†=Variables where decreasing values indicate poorer performance
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
Copyright © 2011