10/3/2016
Disclosures
The Neuropsychologist and Youth Concussion: Practicing Competently, Effectively, and Ethically in a Chaotic, Dynamic, Emerging Frontier National Academy of Neuropsychology Annual Conference October 20, 2016 Presenter:
Rosemarie Scolaro Moser, PhD, ABN, ABPP‐RP Director, Neuropsychologist Sports Concussion Center of New Jersey at the RSM Psychology Center Princeton, New Jersey Adjunct Professor, Widener University
• Past reimbursement from Pearson. • Past reimbursement from ImPACT Applications. • Past consultant for the International Brain Research Foundation. • Book sale proceeds from “Ahead of the Game” Dartmouth College Press. • Speaking engagements. • Owner of the SCCNJ.
Warning: This field is changing so rapidly that whatever I say here today may not apply six months from now…so please keep up with the research and guidelines.
A Brief Introduction to the Learning Objectives
Learning Objective One: Critical Differences in Practice
Learning Objectives 1. Understand the critical differences in the clinical and professional practice of general pediatric neuropsychology vs. neuropsychological practice in youth concussion; 2. Become knowledgeable about the role and activities of the neuropsychologist in the identification, treatment, and management of youth concussion; 3. Review the current research and guidelines that are guiding competent, ethical evidenced based concussion practice;
• • • • • • •
Immediate availability of neuropsychologist Testing‐ short and serial Recovery is expected Team approach School‐oriented in youth Special population‐athletes Guidelines and research are constantly evolving
4. Be able to identify the challenges and controversies surrounding this new, emerging field of practice.
1
10/3/2016
Learning Objective Two: Role of Neuropsychologist • • • • • • • • • •
The most well‐positioned and knowledgeable in concussion identification, testing, treatment, and management. Multifaceted and Fluid Initial Identifier and Treater Treatment Management Coordinator Educator to School and Athletic Personnel Baseline Group Tester and Consultant Team Doctor Academic Planning Consultant Last Resort Referral‐Post Concussion Syndrome Psychotherapist and Behavioral Specialist
Why consult a Neuropsychologist? • Trained in understanding brain functions. • Trained to interpret neurocognitive testing. • Understands effects of individual’s premorbid profile (LD, ADHD, Dementia, Long‐term Intellectual functioning, Personality, Culture, Ethnicity) and extraneous factors on test performance. • Sensitive to the emotional component of mild traumatic brain injury and the subtle effects on the quality of life.
Important facts about the Neuropsychologist in Concussion Education and Treatment:
Important facts about the Neuropsychologist in Concussion Education and Treatment • The National Athletic Trainers’ Association recommends that a neuropsychologist should ideally be part of the sports‐medicine team. • “It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology (ABN), the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) that neuropsychologists should be included among the licensed healthcare professionals authorized to evaluate, clinically manage, and provide return to play clearance for athletes who sustain a sports‐ related concussion.”
• Neuropsychologists created and implemented the first baseline and post‐concussion testing programs in existence, and the first program for professional sports. • Neuropsychologists have conducted the most large‐scale research over the past two decades in the area of concussion. • The Consensus Statement of the 4th International Conference on Concussion in Sport held in Zurich, November 2012 states that for the “Child and Adolescent Athlete…In this age group, it is more important to consider the use of trained paediatric neuropsychologists to interpret assessment data…” • The chair of the concussion committees of the National Hockey League and the Major Soccer League is a neuropsychologist.
Learning Objective Three: Research and Guidelines
Sports Neuropsychology Society (SNS) Sports Neuropsychology: Definition, Qualifications, and Training Guidelines An Official Position of the Sports Neuropsychology Society Sports Neuropsychology Defined: A subspecialty of clinical neuropsychology that applies the science and understanding of brain‐ behavior relationships to the assessment and treatment of sports‐ related brain injury. The practice of sports neuropsychology requires education, training, experience, and competence in the primary field of clinical neuropsychology, followed by a secondary specialization through experience and understanding of applying clinical neuropsychology to the unique demands of evaluating and treating brain injury in the sports domain.
Numerous Guidelines‐Ever Evolving Identification…Treatment…Management…Education • • • • •
Zurich‐International Consensus Conference‐2012 Berlin‐ Meeting October 2016 CDC‐P Pediatric mTBI 2015 AAN 2013 NAN position papers; SNS papers & resources
2
10/3/2016
Guidelines for Evaluation, Treatment, Management
• Moser, Iverson, Echemendia, et al. (2007). Neuropsychological evaluation in the diagnosis and management of sports‐related concussion. Archives of Clinical Neuropsychology, 22 909‐916. • Echemendia, Iverson, McCrea, et al. (2012). Role of neuropsychologists in the evaluation and management of sport‐related concussion: An inter‐ organizational position statement. Archives of Clinical Neuropsychology, 27, 119‐122.
Learning Objective Four: Challenges & Controversies • • • • • • • •
Is Baseline testing valuable? How often to re‐baseline? When and how often to re‐test (post‐concussion)? Rest vs. Activity? Alternative/Complementary Treatments? Will everyone who has a concussion develop CTE? Helmets and Gadgets? Does Chocolate Milk help?
Pulitzer Prize Winning Journalist Usha Lee McFarling Statnews.com December 2015
Resources • www.sportsneuropsychologysociety.com (SNS) • www.sportsconcussion.com (BIANJ) • www.cdc.gov/concussion (CDC) • www.PreventingConcussions.org (CDC & NFL) • www.MomsTeam.com • www.SportsConcussionNJ.com (SCCNJ) • http://nanonline.org/NAN/_Research_Publica tions/Concussions_in_Sport.aspx (NAN Video)
CHALLENGES The Wild Wild West of Concussion • Everyone is a concussion expert. • Concussion clinics popping up without established standards. • In the Media…reporters looking for experts and controversy, using our profession. • Numerous unvetted, poorly researched, new products looking for endorsers or “scientific advisors.” • Keep your head, keep your ethical and scientific standards.
New York Magazine January 20, 2016
The University of Maryland Has a Burgeoning Chocolate‐Mild Concussion Scandal on Its Hands by Jess Singal On December 22, the University of Maryland published a remarkable press release about some research it had conducted. According to the release, a study conducted by a professor at the UMD School of Public Health had shown that a product called Fifth Quarter Fresh — basically, a fancy, fortified chocolate milk — “helped high school football players improve their cognitive and motor function over the course of a season, even after experiencing concussions.”
3
10/3/2016
Ethical Challenges Six things ‘Concussion’ won’t tell you January 11, 2016| Wall Street Journal – MarketWatch
Standard 1: Resolving Ethical Issues Conflict between Ethics and Organization Demands Standard 2: Competence Education and Maintenance Bases for Judgments Standard 3: Human Relations Multiple Relationships Cooperation with Other Professional Services Delivered to or through Organizations Standard 4: Privacy and Confidentiality Disclosure Standard 5: Advertising and Other Public Statements Media Presentations
Ethical Challenges Standard 6: Record Keeping and Fees Barter arrangements Standard 7: Education and Training Present psychological information accurately Standard 8: Research and Publication Informed Consent Standard 9: Assessment Test Security Proper Administration Standard 10: Therapy Evaluation/testing vs Therapy
Why is youth concussion such an issue now? • • • • • • • • •
Increased Athletic Exposures. Recreational and school‐based sports. Playing year round. Playing multiple sports. Earlier ages than previous generations. More females playing than previous generations. Sports Figures and the Media. New Brain Research and Scientific Advances. Second Impact Syndrome and Legislation.
Why is Youth Concussion such an Issue?
Youth Concussion • Youth seem more vulnerable and susceptible. • Youth may take longer to recover. • Long term effects of concussion may not be known because the brain is still developing. • There seems to be a synergistic effect or predisposition for youth who have learning or attention disorders.
4
10/3/2016
Athlete Reporting Enduring Effects of Concussion in Youth • • • • •
Young athletes fear loss of playing time. They are told, “No pain, no gain.” Peer pressure and bullying. Parent pressure on coaches. Approximately up to 66% of youth don’t report (McCrea, et al, 2004).
Moser , Schatz & Jordan (2005). Neurosurgery . Schatz, Moser et al. (2011) Neurosurgery.
Healthy youth with 2 or more concussions in their past had more symptoms, complaints, and problems with attention than healthy youth who had 1 or no concussions.
Concussion 101
First things First Know Concussion A Mild Traumatic Brain Injury
Concussion (brain) (cerebral) (current) 2016 ICD‐10 Diagnosis Code S06.0 + code Concussion No LOC Concussion LOC 30 minutes or less Concussion LOC unspecified duration
S06.0X0 S06.0X1 S06.0X9
• “…a transitory, complex pathophysiological process affecting the brain, induced by biomechanical forces” (McCrory et al., 2009). • Any change in mental status or consciousness as a result of a blow or force to the head. • Acceleration/Deceleration or Rotational forces. • Most common form of head injury for athletes. • It is a Mild Traumatic Brain Injury. • It should be taken seriously. • Symptoms may be delayed. • Post Concussion Syndrome (persisting 1‐3 Months or more).
Post Concussional Syndrome 2016 ICD‐10 Diagnosis Code F07.81 The organic and psychogenic disturbances observed after closed head injuries. Include subjective physical complaints (i.e. headache, dizziness), cognitive, emotional, behavioral changes. These disturbances can be chronic, permanent, or late emerging.
5
10/3/2016
Facts • Most concussions do not involve loss of consciousness. • CT/MRI scans are typically NORMAL. • Helmets, headbands, and mouth guards have not been shown to prevent concussion. • Not always caused by a direct blow to the head. • No fixed recovery time – the brain requires adequate time to heal. • Symptoms may be delayed following the initial injury. • Amnesia is thought to be a highly significant indicator of the severity of concussion. • We no longer grade concussions. • Many concussions are misdiagnosed. • Each concussion is UNIQUE.
SYMPTOMS OF CONCUSSION • • • • • • • • •
Headache Dizziness Nausea/vomiting Memory/attention/concentration Slowness in information processing Fatigue Visual Disturbance Irritability/Emotionality Sleep Disturbance
What Kind of Symptoms?
• Cognitive • Affective • Physical • Sleep
FACTORS
Immediate Signs • • • • • • • • • • • • •
• • • • • • • • •
Feeling dazed Feeling lightheaded Dizziness Confusion Balance Problems Visual Problems Difficulty remembering Not understanding questions Mental or physical slowness Headache Nausea or vomiting Fatigue Loss of consciousness
“Unseen” COGNITIVE SYMPTOMS OF CONCUSSION
Problems multitasking Slow information processing Increase in errors Distractibility and problems with focus Word finding problems Forgetfulness Easily overwhelmed Problems following busy conversations Confused in noisy, high stimulus environment
Symptoms Affect School, Work, & Life Performance • Physical: Headache, visual difficulties, poor sleep, fatigue, light/sound sensitivity, balance. • Cognitive: Memory and learning deficits, slowed processing, distractibility, lack of focus, decreased executive functions (organization/decision‐ making/judgment), word‐finding difficulties. • Emotional/Behavioral: Irritability, sadness, anxiety, lack of motivation, decreased self‐esteem, social withdrawal. • Sleep: Too much, too little, nocturnal awakening, altered sleep pattern.
6
10/3/2016
Emotional Consequences When Symptoms Persist • • • • • • •
A Revised Factor Structure for the Post‐Concussion Symptom Scale Baseline and Post‐Concussion Factors. Kontos, A, Elbin, RJ, Schatz, P et al. (2012). AJSM.
Depression, Anxiety, Phobia, Somatization Sense of Hopelessness Loss of Peer Group Loss of Identify Affects Family‐Parents Loss of self‐esteem Loss of Self‐confidence to return to sport
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 Revised Factor Structure for the Post‐Concussion Symptom Scale Baseline and Post‐Concussion Factors Kontos, A, Elbin, RJ, Schatz, P et al. (2012). AJSM.
Post‐Concussion Symptom Scale Headache Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Light sensitivity
Noise Sensitivity Irritability Sadness Nervousness Feeling more emotional Numbness of tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems
Female participants reported higher symptoms on all post‐concussion factors than male participants.
Findings of Past Research
Gender Differences Hypotheses
• Females are at higher risk than males for concussions. • Female symptoms last longer than male symptoms. • Females more likely to report symptoms at the 1 and 2 week marks.
• • • •
Neck Strength? Reporting? Hormonal? Different brain structures?
Bazarian et al, 2010; Broshek et al, 2005; Covassin et al, 2012; Colvin et al, 2009; Dick, 2009; Farace & Alves, 2000; Kontos et al, 2012.
7
10/3/2016
A New Retrospective Study* Neurocognitive Differences at Baseline
ImPACT database of university athletic and health services department (2013‐2015). Excluded: 1) older than 23 years; 2) invalid test results. N=1155 ImPACT administrations 32.6% female *Murray, K., Moser, RS, Cabry, R & Schatz, P. (In progress).
Four General Symptom Factors at Baseline
Females had stronger Verbal Memory. F(1,1153)=18.0, p1 Varimax Rotation Component Vestib/cog Emotional Tired Dizziness .846 .197 Balance_probs .806 .048 Vomiting .741 .046 Mentally_foggy .683 .249 Diff_concentrating .601 .217 Nervousness .150 .872 More_emotional .115 .844 Sadness .103 .617 Irritable .276 .529 Sleep_less .080 .074 Fatigue .050 .278 Sensitive_noise .140 .101 Drowsiness .210 .049 Diff_remembering .180 .126 Visual_problems .109 .076 Nausea .006 ‐.013 Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a Rotation converged in 5 iterations.
•
Physical ‐.039 ‐.050 .090 .112 .286 ‐.101 .154 .310 .278 .841 .754 ‐.143 .236 .136 ‐.044 ‐.017
Cognitive .015 .057 .117 .205 .223 .073 .016 .013 .162 ‐.045 .096 .856 .834 ‐.110 .294 ‐.010
Nausea .068 .303 ‐.058 .148 .128 .078 .102 .054 .046 .136 ‐.065 .068 .069 .774 .729 ‐.014
‐.013 ‐.027 ‐.061 .208 ‐.009 ‐.008 .049 ‐.065 .012 .002 ‐.014 ‐.001 ‐.007 ‐.003 ‐.008 .987
Significant difference (p (i.e., improved) compared to T1 and T2; Reaction Time, Total Symptoms: T3
