Showing papers by "Grant L. Iverson published in 2009"

An integrated review of recovery after mild traumatic brain injury (mtbi): implications for clinical management

Abstract: The diagnosis and treatment of mild traumatic brain injury (MTBI)have historically been hampered by an incomplete base of scientific evidence to guide clinicians. One question has been most elusive to clinicians and researchers alike: What is the true natural history of MTBI? Fortunately, the science of MTBI has advanced more in the last decade than in the previous 50 years, and now reaches a maturity point at which the science can drive an evidence-based approach to clinical management. In particular, technological advances in functional neuroimaging have created a powerful bridge between the clinical and basic science of MTBI in humans. Collectively, findings from clinical, basic science, and functional neuroimaging studies now establish a foundation on which to build integrative theories and testable hypotheses around a comprehensive model of MTBI recovery. We review the current scientific literature on postconcussion symptom recovery, neuropsychological outcome, and neurophysiological healing after MTBI. Special emphasis is placed on how the new evidence base can help guide clinicians in the evaluation and management of military-related MTBI.

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

Abstract: This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

Active rehabilitation for children who are slow to recover following sport-related concussion.

Abstract: Primary objective: To present an innovative approach to the management of children who are slow to recover after a sport-related concussion.Research design: The article describes the underlying principles and the development of specific interventions for a new rehabilitation programme as well as preliminary data on pre- and post-rehabilitation changes in outcome measures.Methods and procedures: Development of the intervention was done using multiple perspectives including that of the literature, of experts in the field of traumatic brain injury and of experienced clinicians involved with the paediatric and adolescent MTBI clientele. A logic model was developed providing sound theoretical background to the intervention. The intervention was implemented and evaluated with a sample of 16 children and adolescents.Main outcomes and results: The presented cases suggest that involvement in controlled and closely monitored rehabilitation in the post-acute period may promote recovery in children and adolescents wh...

Contributions of neuroimaging, balance testing, electrophysiology and blood markers to the assessment of sport-related concussion

Abstract: Objective: To review the diagnostic tests and investigations used in the management of sports concussion, in the adult and paediatric populations, to (a) monitor the severity of symptoms and deficits, (b) track recovery and (c) advance knowledge relating to the natural history and neurobiology of the injury Design: Qualitative literature review of the neuroimaging, balance testing, electrophysiology, blood marker and concussion literature Intervention: PubMed and Medline databases were reviewed for investigations used in the management of adult and paediatric concussion, including structural imaging (computerised tomography, magnetic resonance imaging, diffusion tensor imaging), functional imaging (single photon emission computerised tomography, positron emission tomography, functional magnetic resonance imaging), spectroscopy (magnetic resonance spectroscopy, near infrared spectroscopy), balance testing (Balance Error Scoring System, Sensory Organization Test, gait testing, virtual reality), electrophysiological tests (electroencephalography, evoked potentials, event related potentials, magnetoencephalography, heart rate variability), genetics (apolipoprotein E4, channelopathies) and blood markers (S100, neuron-specific enolase, cleaved Tau protein, glutamate) Results: For the adult and paediatric populations, each test has been classified as being: (1) clinically useful, (2) a research tool only or (3) not useful in sports-related concussion Conclusions: The current status of the diagnostic tests and investigations is analysed, and potential directions for future research are provided Currently, all tests and investigations, with the exception of clinical balance testing, remain experimental There is accumulating research, however, that shows promise for the future clinical application of functional magnetic resonance imaging in sport concussion assessment and management

Neuropsychological functioning following complicated vs. uncomplicated mild traumatic brain injury

Abstract: Objective: It would be logical to assume that patients with intracranial abnormalities (i.e. complicated MTBIs) would have worse outcome than patients without these abnormalities (i.e. uncomplicated MTBIs). However, the literature is limited and somewhat mixed regarding outcome in patients with complicated mild TBIs. The purpose of this study is to employ a carefully controlled research design to compare the acute neuropsychological functioning of patients following complicated and uncomplicated MTBI.Method: Participants were 20 patients with complicated MTBI and 20 patients with uncomplicated MTBI selected from an archival database of 465 patients. Patients were carefully matched on age, education, gender, ethnicity, days assessed post-injury and mechanism of injury. Patients were assessed an average of 3.5 days (SD = 1.9) post-injury with 13 common cognitive variables.Results: There were significant group differences on only three of the 13 cognitive measures (complicated mild TBI worse than uncomplicat...

Challenges associated with post-deployment screening for mild traumatic brain injury in military personnel.

Abstract: There is ongoing debate regarding the epidemiology of mild traumatic brain injury (MTBI) in military personnel. Accurate and timely estimates of the incidence of brain injury and the prevalence of long-term problems associated with brain injuries among active duty service members and veterans are essential for (a) operational planning, and (b) to allocate sufficient resources for rehabilitation and ongoing services and supports. The purpose of this article is to discuss challenges associated with post-deployment screening for MTBI. Multiple screening methods have been used in military, Veterans Affairs, and independent studies, which complicate cross-study comparisons of the resulting epidemiological data. We believe that post-deployment screening is important and necessary--but no screening methodology will be flawless, and false positives and false negatives are inevitable. Additional research is necessary to refine the sequential screening methodology, with the goal of minimizing false negatives during initial post-deployment screening and minimizing false positives during follow-up evaluations.

Does familiarity with computers affect computerized neuropsychological test performance

Abstract: The purpose of this study was to determine whether self-reported computer familiarity is related to performance on computerized neurocognitive testing. Participants were 130 healthy adults who self-reported whether their computer use was "some" (n = 65) or "frequent" (n = 65). The two groups were individually matched on age, education, sex, and race. All completed the CNS Vital Signs (Gualtieri & Johnson, 2006b) computerized neurocognitive battery. There were significant differences on 6 of the 23 scores, including scores derived from the Symbol-Digit Coding Test, Stroop Test, and the Shifting Attention Test. The two groups were also significantly different on the Psychomotor Speed (Cohen's d = 0.37), Reaction Time (d = 0.68), Complex Attention (d = 0.40), and Cognitive Flexibility (d = 0.64) domain scores. People with "frequent" computer use performed better than people with "some" computer use on some tests requiring rapid visual scanning and keyboard work.

Special featureConsensus Statement on Concussion in Sport – The 3rd International Conference on Concussion in Sport Held in Zurich, November 2008

Abstract: This paper is a revision and update of the recommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. 2 The Zurich Consensus statement is designed to build on the principles outlined in the original Vienna and Prague documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document. This document is developed for use by physicians, therapists, certified athletic trainers, health professionals, coaches and other people involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving and therefore management and return to play decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document and/or the Sports Concussion Assessment Tool (SCAT2) card and neither is subject to any copyright restriction. The authors request, however that the document and/or the SCAT2 card be distributed in their full and complete format. The following focus questions formed the foundation for the Zurich concussion consensus statement:

Minimizing misdiagnosis: psychometric criteria for possible or probable memory impairment.

Abstract: Background/Aims: Memory impairment can be easily misdiagnosed in older adults because obtaining some low scores is common. The objective of the present study is to present new psych

Healthy children and adolescents obtain some low scores across a battery of memory tests.

Abstract: Obtaining some low memory scores across a battery of tests is common. The purpose of this study was to examine the prevalence of low scores on the Children's Memory Scale (CMS). Participants were 1000 children and adolescents between 5 and 16 years of age from the CMS standardization sample. Consistent with research on other batteries, having some low memory scores is common in healthy children and adolescents. The prevalence of low memory scores also increases with lower intelligence. Clinicians should be cautious when interpreting isolated low memory scores as sole evidence of memory impairment. Knowing the prevalence of low scores as a supplement to clinical judgment should reduce the likelihood of misdiagnosing memory problems.

Sex differences in self-reported symptoms after aerobic exercise in non-injured athletes: implications for concussion management programmes

Abstract: Background: After a concussion, when symptoms have decreased substantially at rest, it is recommended that athletes begin light aerobic exercise before progressing to sport specific exercise. The British Columbia Concussion Rehabilitation Programme (BC-CRP) uses a standardized cognitive and exercise test protocol designed to indicate when an athlete should progress to sport-specific exercise after a concussion. Objective: To document the effects of exercise on symptom reporting in healthy, uninjured, male and female amateur athletes. Design: Quasi-experimental, pretest–post-test, nonequivalent groups design. Methods: Before the exercise protocol, 45 female and 30 male young amateur athletes completed computerized cognitive testing, symptom ratings and balance testing. The 15-minute cycle ergometry protocol, conducted at 90 revolutions/minute, was as follows: 0–2 minutes at 0 W tension, 2–5 minutes at 50 W, 5–8 minutes at 100 W, 8–11 minutes at 150 W and 11–14 minutes at 200 W tension followed by a 1-minute cooling-down period. After exercise, participants completed symptom ratings, balance testing and perceived exertion ratings. Self-reported symptoms were assessed using an abbreviated version of the Post-Concussion Scale. Results: Significant increases in self-reported balance problems, numbness and tingling were seen for both genders after aerobic exercise. For women, emotional symptoms such as irritability, sadness, nervousness and feeling more emotional decreased significantly after aerobic exercise. Headache also decreased in the women, but no significant change was seen in the men. Conclusions: Sex differences exist for symptom reporting after aerobic exercise. Both genders report increases in somatic symptoms, but only women report decreases in emotional symptoms. The concept of being “asymptomatic” after exercise should be reconsidered to include expected mild increases and decreases in certain symptoms.

Identifying Neurocognitive Impairment in Depression Using Computerized Testing

Abstract: There is considerable interest in the identification of neurocognitive impairment in patients with depression. The purpose of this study is to illustrate a methodology for identifying frank neurocognitive impairment in clinical practice and research using a computerized battery of neuropsychological tests. Participants were 100 adult patients with depression who were not on antidepressants. They were carefully matched on age, education, gender, and ethnicity to 100 healthy adult control subjects. All participants completed the Central Nervous System Vital Signs (CNS-VS) computerized assessment battery, which takes approximately 30-40 minutes to administer. Patients with depression performed more poorly than controls on all five domain scores (Cohen's d ranged from d = .37 to .72). When using two or more scores below the 5th percentile as the cutoff for frank neurocognitive impairment, 31.0% of the depressed sample and only 5.0% of the control sample scored in this range. In this study, patients with depression were 8.5 times more likely to have two or more index scores that were below the 5th percentile. Computerized testing, using the interpretive methodology presented, represents an efficient methodology for identifying cognitive problems in patients who present with untreated depression.

Interpretation of the RBANS in Inpatient Psychiatry: Clinical Normative Data and Prevalence of Low Scores for Patients with Schizophrenia

Abstract: The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998) is a screening battery designed to measure attention and processing speed, expressive language, visual-spatial and constructional abilities, and immediate and delayed memory. Clinical normative data for a large sample of inpatients and outpatients with schizophrenia spectrum disorders is available (Wilk, Gold, Humber, Dickerson, Fenton, & Buchanan, 2004). The purpose of this study was to replicate and extend the clinical normative data for the RBANS for use in inpatient psychiatry. Participants were 174 inpatients from a provincial psychiatric hospital with a diagnosis of schizophrenia spectrum disorder. Median performance on the RBANS was 1-2 standard deviations (SDs) below the mean. Patients with more than 12 years of education performed significantly better on every index score than patients with 12 or fewer years of education. Men performed better than women on the Visuospatial/Constructional Index (Cohen's d= .47). When examining all five Index scores simultaneously, it was common for inpatients to obtain three or more frankly impaired scores (i.e., less than the 2nd percentile). Overall, the performance of this inpatient sample was very similar to the clinical normative data presented by Wilk et al. (2004). Detailed normative tables by diagnosis, education, and gender are provided.

Rapid Computerized Assessment of Neurocognitive Deficits in Bipolar Disorder

Abstract: The purpose of this study is to illustrate the clinical usefulness of a computerized neuropsychological battery for identifying neurocognitive deficits in adults with bipolar disorder. Participants were 47 outpatients with bipolar disorder who were individually matched on age, education, sex, and ethnicity to 47 control subjects from the Central Nervous System (CNS) Vital Signs normative database. CNS Vital Signs is comprised of seven common neuropsychological measures, and it generates 15 primary scores that are used to calculate five domain scores (Memory, Psychomotor Speed, Reaction Time, Cognitive Flexibility, and Complex Attention). There was a significant multivariate effect and statistically significantly worse scores for those in the bipolar group on all five domain scores (medium to large effect sizes). When using two or more scores below the fifth percentile as a cutoff for neurocognitive impairment, 42.6% of the bipolar sample and only 6.4% of the control sample scored in this range. A subset o...

Position Paper Secretive Recording of Neuropsychological Testing and Interviewing: Official Position of the National Academy of Neuropsychology †

Abstract: Neuropsychologists are occasionally asked to have neuropsychological testing observed via the presence of a third party, through one-way mirrors, or with audio or video monitoring or recording devices. The primary reasons for not allowing observation are its effect on the validity of the examination results and the security of copyrighted test materials. To overcome the problem of observer effects on the examinee’s performance, some individuals have suggested that examinations be monitored or recorded without the examinee’s awareness (i.e., secretly). However, secretive recording of neuropsychological interviews and testing is deceptive, which is inconsistent with ethical principles. In addition, such recording may affect the behavior of the examiner. For these reasons, neuropsychologists do not, and should not, encourage, condone, or engage in secret recording of neuropsychological interviews or testing.

Investigation of cognitive screening measures in patients with brain tumors: Diagnostic accuracy and correlation with quality of life

Abstract: e13000 Background: Brief cognitive screening measures are often selected by clinicians and researchers for brain tumor patients, primarily because of their ease of use. Currently, the Mini Mental S...