Showing papers by "Grant L. Iverson published in 2013"

Consensus statement on concussion in sport

Abstract: 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.

Consensus statement on concussion in sport: The 4th international conference on concussion in sport, Zurich, November 2012

Abstract: Paul McCrory, MBBS, PhD*; Willem H. Meeuwisse, MD, PhD†; Mark Aubry, MD‡; Robert C. Cantu, MD§; Jiři Dvořak, MD||; Ruben J. Echemendia, PhD¶; Lars Engebretsen, MD, PhD#; Karen Johnston, MD, PhD**; Jeffrey S. Kutcher, MD††; Martin Raftery, MBBS‡‡; Allen Sills, MD§§; Brian W. Benson, MD, PhD||||; Gavin A. Davis, MBBS¶¶; Richard Ellenbogen, MD##; Kevin M. Guskiewicz, PhD***; Stanley A. Herring, MD†††; Grant L. Iverson, PhD‡‡‡; Barry D. Jordan, MD§§§; James Kissick, MD||||||; Michael McCrea, PhD¶¶¶; Andrew S. McIntosh, PhD###; David Maddocks, LLB, PhD****; Michael Makdissi, MBBS, PhD††††; Laura Purcell, MD‡‡‡‡; Margot Putukian, MD§§§§; Kathryn Schneider, PhD||||||||; Charles H. Tator, MD, PhD¶¶¶¶; Michael Turner, MD####

Is Rest After Concussion "The Best Medicine?": Recommendations for Activity Resumption Following Concussion in Athletes, Civilians, and Military Service Members

Abstract: Practice guidelines universally recommend an initial period of rest for people who sustain a sports-related concussion or mild traumatic brain injury (MTBI) in daily life or military service. This practice is difficult to reconcile with the compelling evidence that other health conditions can be worsened by inactivity and improved by early mobilization and exercise. We review the scientific basis for the recommendation to rest after MTBI, the challenges and potential unintended negative consequences of implementing it, and how patient management could be improved by refining it. The best available evidence suggests that complete rest exceeding 3 days is probably not helpful, gradual resumption of preinjury activities should begin as soon as tolerated (with the exception of activities that have a high MTBI exposure risk), and supervised exercise may benefit patients with persistent symptoms.

The effects of rest and treatment following sport-related concussion: a systematic review of the literature

Abstract: Objective To evaluate the evidence for rest, treatment, and rehabilitation following sport-related concussion (SRC). Data sources PubMed, CINAHL, PsychInfo, Cochrane Controlled Trials Registers, Health STAR, Sport Discus, EMBASE, Web of Science, and ProQuest. Study selection Articles were included if they met the following criteria: original research, reported SRC as a source of injury, and evaluated the effect of rest or treatment. Data extraction Study design, participants, treatment, outcome measures, and key findings. Data synthesis Three studies met the inclusion criteria for evaluating the effects of rest and twelve for treatment. Low-intensity aerobic exercise may be of benefit. Conclusions The current evidence evaluating the effect of rest and treatment following SRC is sparse. An initial period of rest may be of benefit. Low-level exercise and multimodal physiotherapy may be of benefit for those who are slow to recover. There is a strong need for high level studies evaluating the effects of rest and treatment following SRC.

Advances in neuropsychological assessment of sport-related concussion

Abstract: Objective To critically review the literature from the past 12 years regarding the following key issues in sports-related neuropsychological assessment: (1) the advantages and disadvantages of different neuropsychological assessment modalities; (2) the evidence for and against the current paradigm of baseline/postinjury testing; (3) the role of psychological factors in the evaluation and management of concussion; (4) advances in the neuropsychological assessment of children; (5) multi-modal assessment paradigms; (6) the role of the neuropsychologist as part of the sports healthcare team and (6) the appropriate administration and interpretation of neuropsychological tests. Design Targeted computerised literature review (MEDLINE, PubMed, CINAHL and PsychInfo) from 2000 to the present using key words: neuropsychological, neurocognitive, assessment, testing, concussion and sports. Results More than 2600 articles were identified using key word searches of the databases, including many duplicates. Several books were also reviewed. The articles were pared down for review if they specifically addressed the key areas noted above. Conclusions Traditional and computerised neuropsychological tests are useful in the evaluation and management of concussion. Brief cognitive evaluation tools are not substitutes for formal neuropsychological assessment. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing. Although scant, research suggests that psychological factors may complicate and prolong recovery from concussion in some athletes. Ageappropriate symptom scales for children have been developed but research into age-appropriate tests of cognitive functions lags behind. Neuropsychologists are uniquely qualified to interpret neuropsychological tests and can play an important role within the context of a multifaceted-multimodal approach to manage sportsrelated concussions.

What is the lowest threshold to make a diagnosis of concussion

Abstract: Objective The purpose of this review is to examine the evidence for determining the lowest threshold for diagnosing a sport-related concussion. Data Sources MEDLINE, CINAHL, EMBASE, Mosby9s Index, PsycEXTRA, PsycINFO and Scopus. Key words included sports concussion, concussion assessment, diagnosis, concussion symptoms, onfield assessment and sports-related traumatic brain injury. Results The majority of concussions in sport occur without loss of consciousness or frank neurological signs. Some of the hallmark signs of acute concussion include mental confusion, memory and balance disturbance. Over the course of the first 24 h, the most common symptoms include headache, nausea, dizziness and balance problems, blurred vision or other visual disturbance, confusion, memory loss and ‘fatigue’. Symptoms such as tiredness, irritability, nervousness or anxiety, sleep disturbance and sensitivity to light or noise may be noticed in the days after injury. The pathophysiology of sports concussion remains poorly understood. There appears to be a period of vulnerability following concussion in which an overlapping injury might cause magnified pathophysiology. Conclusions Sport-related concussions can be difficult to diagnose. Concussion produces an evolving constellation of somatic, cognitive and neurobehavioral symptoms that are typically most severe during the earliest acute postinjury period (ie, within the first 24–48 h) and diminish over a matter of several days to weeks in the majority of athletes. Athletes suspected of concussion should be removed from play and evaluated thoroughly.

Who gets recruited in mild traumatic brain injury research

Abstract: Selection bias, common in traumatic brain injury research, limits the clinical usefulness and generalizability of study findings. The purpose of this study was to examine the effect of different inclusion and exclusion criteria on patient enrollment, and the implications for generalizability, in a mild traumatic brain injury (MTBI) study. The study was conducted at the emergency department (ED) of Tampere University Hospital. Our aim was to study outcome from MTBI in patients who do not have pre-existing conditions or other confounding factors. For this, all consecutive patients with acute head trauma (n=1344) were screened. The study design included three inclusion criteria and nine exclusion criteria. The World Health Organization Collaborating Center for Neurotrauma Task Force criteria for MTBI were used. Of all patients screened, 934 (69.5%) fulfilled the MTBI criteria. For those fulfilling the MTBI criteria, various inclusion and exclusion criteria were applied in order to yield those eligib...

Normative Data for the Balance Error Scoring System in Adults

Abstract: Background. The balance error scoring system (BESS) is a brief, easily administered test of static balance. The purpose of this study is to develop normative data for this test. Study Design. Cross-sectional, descriptive, and cohort design. Methods. The sample was drawn from a population of clients taking part in a comprehensive preventive health screen at a multidisciplinary healthcare center. Community-dwelling adults aged 20-69 (N = 1, 236) were administered the BESS within the context of a fitness evaluation. They did not have significant medical, neurological, or lower extremity problems that might have an adverse effect on balance. Results. There was a significant positive correlation between BESS scores and age (r = .34). BESS performance was similar for participants between the ages of 20 and 49 and significantly declined between ages 50 and 69. Men performed slightly better than women on the BESS. Women who were overweight performed significantly more poorly on the test compared to women who were not overweight (P < .0001; Cohen's d = .62). The BESS normative data are stratified by age and sex. Conclusions. These normative data provide a frame of reference for interpreting BESS performance in adults who sustain traumatic brain injuries and adults with diverse neurological or vestibular problems.

Clinical utility of the Conners' Continuous Performance Test-II to detect poor effort in U.S. military personnel following traumatic brain injury.

Abstract: The purpose of this study is to examine the clinical utility of the Conners' Continuous Performance Test (CPT-II) as an embedded marker of poor effort in military personnel undergoing neuropsychological evaluations following traumatic brain injury. Participants were 158 U.S. military service members divided into 3 groups on the basis of brain injury severity and performance (pass/fail) on 2 symptom validity tests: Mild Traumatic Brain Injury (MTBI)-Pass (n = 87), MTBI-Fail (n = 42), and severe traumatic brain injury (STBI)-Pass (n = 29). The MTBI-Fail group performed worse on the majority of CPT-II measures compared with both the MTBI-Pass and STBI-Pass groups. When comparing the MTBI-Fail group and MTBI-Pass groups, the most accurate measure for identifying poor effort was the Commission T score. When selected measures were combined (i.e., Omissions, Commissions, and Perseverations), there was a very small increase in sensitivity (from .26 to .29). When comparing the MTBI-Fail group and STBI-Pass groups, the most accurate measure for identifying poor effort was the Omission and Commissions T score. When selected measures were combined, sensitivity again increased (from .24 to .45). Overall, these results suggest that individual CPT-II measures can be useful for identifying people who are suspected of providing poor effort from those who have provided adequate effort. However, due to low sensitivity and modest negative predictive power values, this measure cannot be used in isolation to detect poor effort, and is largely useful as a test to "rule in," not "rule out" poor effort.

Normative data for the modified balance error scoring system in adults

Abstract: Primary objective: Head trauma, with or without injury to the brain, can impair balance and postural stability. The Modified Balance Error Scoring System (M-BESS) is a rapid, standardized, objective bedside test that can be helpful for monitoring recovery of balance and postural stability following head trauma. The purpose of this study is to develop preliminary normative data for this test for adults.Methods and procedures: Adults between the ages of 20–69 (n = 1234) were administered the M-BESS as part of a comprehensive preventive health screen. They did not have significant medical, neurological or lower extremity problems that might have an adverse effect on balance.Main outcomes and results: M-BESS performance significantly declined with age. Men and women performed similarly on the M-BESS. There was a small significant difference in M-BESS performance, with obese men performing more poorly than non-obese men and a larger significant difference between obese and non-obese women.Conclusions: The M-BE...

Risk factors for postconcussion symptom reporting after traumatic brain injury in U.S. military service members.

Abstract: The purpose of this study was to identify factors that are predictive of, or associated with, postconcussion symptom reporting after traumatic brain injury (TBI) in the U.S. military. Participants were 125 U.S. military service members (age: M=29.6 years, standard deviation [SD]=8.9, range=18–56 years) who sustained a TBI, divided into two groups based on symptom criteria for postconcussional disorder (PCD): PCD-Present (n=65) and PCD-Absent (n=60). Participants completed a neuropsychological evaluation at Walter Reed Army Medical Center (M=9.4 months after injury, SD=9.9; range: 1.1 to 44.8). Factors examined included demographic characteristics, injury-related variables, psychological testing, and effort testing. There were no significant group differences for age, sex, education, race, estimated premorbid intelligence, number of deployments, combat versus non-combat related injury, or mechanism of injury (p>0.098 for all). There were significant main effects for severity of body injury, durati...

Day of injury assessment of sport-related concussion

Abstract: Objective To conduct a critical review of the literature on instruments currently used in the assessment of sport-related concussion on the day of injury. Data sources Computerised searches of the literature posted to MEDLINE, PubMed, CINAHL, PsychInfo and Cochrane Library from 1 January 1982 through 21 August 2012. Key words and medical embedded subheadings (MeSH) terms relevant to sport-related concussion were applied, which identified 577 articles. Study selection In addition to MeSH term and key word criteria, a study was included in the analysis if the article: (1) was published in English, (2) represented original research, (3) pertained to sport-related concussion (ie, not non-sports traumatic brain injury), (4) included assessment or diagnostic data collected within 24 h of the injury event and (5) involved human research. A total of 41 studies qualified for review. Data extraction All articles were examined to determine if the study met the additional requirements for inclusion. A standardised method was used to document critical elements of the study design, population, tests employed and key findings. Data synthesis A large number of studies were analysed that reported data from testing conducted within 24 h of injury. These studies collectively demonstrated that a number of instruments are capable of measuring the acute effects of concussion across several domains, such as symptoms, cognition and balance. Results Relating to specific assessment domains are compiled in separate tables and an interpretive summary of the findings is provided. Conclusions Several well-validated tests are appropriate for use in the assessment of acute concussion in the competitive sporting environment. These tests provide important data on the symptoms and functional impairments that clinicians can incorporate into their diagnostic formulation, but they should not solely be used to diagnose concussion.

Rapid screening for perceived cognitive impairment in major depressive disorder.

Abstract: Background Subjectively experienced cognitive impairment is common in patients with mood disorders. The British Columbia Cognitive Complaints Inventory (BC-CCI) is a 6-item scale that measures perceived cognitive problems. The purpose of this study is to examine the reliability of the scale in healthy volunteers and depressed patients and to evaluate the sensitivity of the measure to perceived cognitive problems in depression. Methods Participants were 62 physician-diagnosed inpatients or outpatients with depression, who had independently confirmed diagnoses on the Structured Clinical Interview for DSM-IV, and a large sample of healthy community volunteers (n=112). Results The internal consistency reliability of the BC-CCI was α=.86 for patients with depression and α=.82 for healthy controls. Principal components analyses revealed a one-factor solution accounting for 54% of the total variability in the control sample and a 2-factor solution (cognitive impairment and difficulty with expressive language) accounting for 76% of the variance in the depression sample. The total score difference between the groups was very large (Cohen's d=2.2). Conclusions The BC-CCI has high internal consistency in both depressed patients and community controls, despite its small number of items. The test is sensitive to cognitive complaints in patients with depression.

Post-Concussion Symptom Reporting after Multiple Mild Traumatic Brain Injuries

Abstract: The relationship between previous mild traumatic brain injury/injuries (MTBI) and recovery from a subsequent MTBI may be complex. The present study investigated three factors hypothesized to influence this relation: (1) the number of prior MTBIs, (2) the interval between MTBIs, and (3) the certainty level of previous MTBIs. The study design was retrospective cross-sectional. Participants (N=105) were evaluated at a concussion clinic on average 1 month after sustaining an MTBI, defined by World Health Organization diagnostic criteria. Approximately half the sample had at least one previous MTBI. Subgroups with 0, 1, or 2+ previous MTBIs did not differ in levels of current post-concussion symptom reporting on the British Columbia Post-Concussion Symptom Inventory. Time since the most recent previous MTBI was significantly associated with current post-concussion symptom reporting. This relation was best characterized as logarithmic; i.e., the impact of previous MTBI(s) lessens exponentially as time ...

Understanding and Using Multivariate Base Rates with the WAIS–IV/WMS–IV

Abstract: When healthy people complete a battery of tests, a substantial minority will obtain one or more low scores. When considering a single WAIS–IV/WMS–IV subtest in isolation, only 9% of healthy adults will obtain a score of 6 or lower. However, when considering the 20 primary subtests from the WAIS–IV/WMS–IV simultaneously, 61% will have one or more scores of 6 or lower. Low scores in healthy adults and older adults might be attributable to measurement error (broadly defined), normative sample characteristics (i.e., having healthy people, rather than clinical groups, at the lower end of the distribution), long-standing weaknesses in certain areas, fluctuations in motivation and effort, psychological interference, and other situational factors such as inattentiveness, fatigue, or minor illness. This chapter presents five psychometric principles to consider when interpreting multiple test scores. Low scores are common across all batteries of tests (Principle 1), the number of low scores depends on the cut-off score used (Principle 2), the number of low scores obtained increases with the number of tests administered and interpreted (Principle 3), the number of low scores can change depending on the demographic characteristics of a sample (Principle 4), and different levels of intellectual functioning are inherently going to have different rates of low scores (Principle 5). Numerous look-up tables that illustrate the base rates of low scores in healthy adults and older adults across different combinations of WAIS–IV and WMS–IV indexes and subtests are provided. Multivariate base rates can be used to determine if a person’s profile (i.e., the number of low scores) is broadly normal or uncommon in healthy people. With this information, clinicians are better able to guard against over-interpreting an isolated low score. Using multivariate base rates improves the diagnostic accuracy and interpretation of the WAIS–IV and WMS–IV.

Systematic review of neurocognition and occupational functioning in major depressive disorder

Abstract: Occupational impairment accounts for much of the burden and economic costs associated with major depressive disorder (MDD). Many studies have documented neurocognitive deficits in MDD, and depression-associated cognitive dysfunction would be expected to have significant effects on occupational functioning. We systematically reviewed the literature for studies on neurocognition and occupational functioning in MDD. Electronic databases (e.g., MEDLINE, PsychInfo and Cochrane Clinical Trials) were searched using appropriate terms and bibliographies of relevant publications were scanned for additional citations. Two reviewers independently reviewed papers for inclusion and data extraction, with conflicts resolved by consensus. Inclusion criteria were diagnosis of MDD using validated criteria (e.g., DSM‑IV or ICD‑10), use of objective neuropsychological tests and use of a specific measure of occupational functioning. Of 630 citations identified in the initial search, only two studies met inclusion criteria and were included in a qualitative review. Both had significant methodological limitations. Nonetheless, the depressed samples had significant neurocognitive deficits that were associated with employment status and work impairment. Neurocognitive dysfunction is probably associated with impairment in occupational functioning in individuals with MDD, but the evidence is limited. Further research should examine specific cognitive domains, and use validated measures of work functioning and productivity.

WAIS-IV, WMS-IV, and ACS : advanced clinical interpretation

Abstract: This book provides users of the Wechsler Adult Intelligence Scale (WAIS-IV) with information on applying the WAIS-IV, including additional indexes and information regarding use in special populations for advanced clinical use and interpretation. The book offers sophisticated users of the WAIS-IV and Wechsler Memory Scale (WMS-IV) guidelines on how to enhance the clinical applicability of these tests. The first section of the book provides an overview of the WAIS-IV, WMS-IV, and new Advanced Clinical Solutions for Use with the WAIS-IV/WMS-IV (ACS). In this section, examiners will learn: normal versus atypical score variability; low-score prevalence in healthy adults versus clinical populations; and assessing whether poor performance reflects a decline in function or is the result of suboptimal effort New social cognition measures found in the ACS are also presented. The second part focuses on applying the topics in the first section to specific clinical conditions, including recommended protocols for specific clientele (e.g. using demographically adjusted norms when evaluating individuals with brain injury). Common clinical conditions are discussed, including Alzheimer's disease, mild cognitive impairment, traumatic brain injury, and more. Each chapter provides case examples applying all three test batteries and using report examples as they are obtained from the scoring assistant. Finally, the use of the WAIS-IV/WMS-IV and the ACS in forensic settings is presented. Features: coverage of administration and scoring of WAIS-IV, WMS-IV and ACS; information contained on the use of WAIS-IV with special populations; case studies in each chapter; and written by the creators of WAIS-IV, WMS-IV and ACS.

Prevalence of low scores in children and adolescents on the test of verbal conceptualization and fluency.

Abstract: It is important to consider the prevalence of low scores when administering a battery of psychological tests. Understanding the prevalence of low scores is important for minimizing false-positive diagnoses of cognitive deficits in clinical practice. The purpose of this study was to expand the literature on base rates for use in children and adolescents. Participants were 408 healthy children and adolescents (M(age) = 13.1 years, SD = 3.7) and 139 children and adolescents (M(age) = 12.4 years, SD = 3.1) diagnosed with a medical, neurological, or learning condition. All participants were administered the Test of Verbal Conceptualization and Fluency (TVCF; Reynolds & Horton, 2006 ). The clinical sample performed significantly lower compared with the healthy control participants on three of the five TVCF scores. When all scores were considered simultaneously, 38% of healthy children obtained one or more scores below the 16th percentile and 15% had one or more scores in the 5th percentile or lower. By comparison, significantly higher proportions of children in the clinical sample had low scores below each of the five cutoffs (i.e., 63% had one or more test scores below the 16th percentile and 37% had one or more scores in the 5th percentile or lower). Our findings illustrate the importance of considering the prevalence of low TVCF scores in everyday clinical practice with children and adolescents.

Acute assessment of brain injuries in ground-level falls.

Abstract: OBJECTIVE:: The purpose of this study was to characterize traumatic brain injuries (TBI) sustained in ground-level falls (GLFs). The focus was on factors associated with acute computed tomographic (CT) findings. METHODS:: The sample included 575 subjects examined and treated at the Tampere University Hospital emergency department (ED). Retrospective data collection consisted of subject- and injury-related data and clinical information from the emergency department. All CT scans were analyzed and systematically coded. RESULTS:: Ground-level falls were the mechanism of injury in 48.3% (n = 278) of the subjects. In the GLF group, independent risk factors for acute traumatic CT findings were long-term alcohol abuse, older age, being found on the ground, and left temporoparietal and occipital location of direct head impact. There were no significant differences in the incidence of any intracranial traumatic lesion type between those with GLFs and other causes of TBI. None of the classic clinical TBI severity markers studied were associated with acute traumatic CT findings in patients with GLFs. CONCLUSIONS:: Older age and long-term alcohol abuse increase the likelihood of acute intracranial CT abnormalities. The pattern of intracranial traumatic CT findings does not differ from other causes of TBI. Clinical signs and indices of TBI severity did not predict traumatic CT findings. Language: en

Predicting Premorbid Ability for WAIS–IV, WMS–IV and WASI–II

Abstract: The estimation of premorbid cognitive functioning is an important component of most neuropsychological evaluations with adults and older adults. Clinicians typically estimate premorbid cognitive skills using background information (e.g., education and occupation) and/or current test scores. Statistical models use multivariate regression techniques to derive equations to predict premorbid ability. Two commonly used approaches include the Test of Premorbid Functioning (TOPF) and the Oklahoma Premorbid Intelligence Estimate (OPIE–IV). The strengths and weaknesses of each model are discussed, and these models are applied to clinical samples. This chapter provides a technical and comprehensive summary of the use of the TOPF and OPIE–IV equations for estimating premorbid cognitive functioning.

Assessing Performance Validity with the ACS

Abstract: The assessment of performance validity requires the identification of cognitive test scores that are atypical in pattern or degree for bona fide neurological, psychiatric, or developmental disorders. Historically, these patterns include impaired attention in the context of normal memory, extremely poor recognition memory following minor injury and at a level inconsistent with that seen in severe traumatic brain injury, and impaired immediate memory in the context of preserved verbal intellectual functions. Although invalid performance can be present in any type of psychological or neuropsychological evaluation, it is particularly important in high stakes assessments (e.g., forensic, medical–legal) where having a specific diagnosis, high levels of symptoms, or demonstrated impairment is advantageous. When negative response bias is present, the test results are not an accurate reflection of the person’s cognitive functioning. This chapter discusses negative response bias and the assessment of performance validity using embedded measures on the WAIS–IV and WMS–IV and the ACS Word Choice Test.

Using the WAIS–IV/WMS–IV/ACS Following Moderate-Severe Traumatic Brain Injury

Abstract: Traumatic brain injuries (TBI) are associated with a variety of cognitive deficits particularly in attention, memory, processing speed, and executive functioning. Impairments in language functioning, perceptual reasoning, and social perception can also occur. Cognitive impairment associated with TBI is quite variable and can range from mild to severe, depending on the nature and severity of the injury, and the assessment of cognitive functioning can be complicated by premorbid abilities, pre-injury health status, and post-injury individual differences. This chapter presents data comparing patients with a moderate-to-severe TBI to healthy controls on WAIS–IV and WMS–IV indexes (including newly developed index scores) and subtests. WAIS–IV/WMS–IV multivariate base rates and variability indicators are also presented. Acquired cognitive deficits can be quantified using the TOPF, OPIE–IV, and Demographic Adjustment to Norms described in previous chapters. The assessment of performance validity is an important component of clinical evaluations in this population. There is growing evidence that deficits in social cognition are associated with TBI. Data are presented showing that social perception deficits are comparable to, or great than, impairments in memory, working memory, and processing speed. This chapter fully illustrates the usefulness of the WAIS–IV/WMS–IV and ACS as part of a comprehensive clinical assessment of patients with TBIs.

Sport concussion assessment tool-second edition in an emergency department setting

Abstract: Objective To investigate the clinical usefulness of the Sport Concussion Assessment Tool-Second Edition (SCAT2) in patients with mild traumatic brain injuries (MTBI). Design A cross-sectional, descriptive study. Setting Emergency Department of Tampere University Hospital, Finland. Patients Patients (N=38, 26 men and 12 women) between the ages of 18 and 60 years, with no premorbid medical or psychiatric conditions, who met the WHO criteria for MTBI were enrolled. Alcohol intoxication was an exclusion criterion. Interventions A broad clinical assessment and the SCAT2 were completed within 4 days postinjury (Median=19.6 h, SD=24.8, Range=2–94.5 h). CT of the head was performed in the ED. A head MRI was done within 1 week postinjury. Main Outcome Measurements Outcome measurements included clinical injury severity markers (loss of consciousness (LOC), GCS, post-traumatic amnesia (PTA), retrograde amnesia (RA), disorientation, and focal neurological deficits), and the SCAT2 subscores and total score. Results The mean SCAT2 total score was 76.4 (SD=9.7, range=52–93). The mean Standardised Assessment of Concussion score was 25.3 (SD=2.1, range=21–30), balance score was 20.9 (SD=6.7, range=8–30), and symptom severity score was 16.6 (SD=14.1, range=0–60). The vast majority of the sample endorsed 5 or more symptoms (89.5%). The SCAT2 total scores and subscores were not significantly associated with the MTBI severity markers (eg, LOC, PTA, and RA) or imaging findings. Conclusions The SCAT2 measures the acute consequences of MTBI reasonably well in many civilian patients with MTBIs. However, the scores do not reflect the clinical or radiological severity of injury. Acknowledgements The authors would like to thank research assistants Anne Simi for her contribution in data collection. Competing interests Grant Iverson has been reimbursed by the government, professional scientific bodies, and commercial organizations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. These include, but are not limited to, the National Academy of Neuropsychology, American Academy of Clinical Neuropsychology, International Neuropsychological Society, US Department of Defense, and Australasian Faculties of Rehabilitation Medicine and Occupational and Environmental Medicine, and the Swiss Accident Insurance Fund. He has a clinical practice in forensic neuropsychology involving individuals who have sustained mild TBIs. He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received honorariums for serving on research panels that provide scientific peer review of programs (eg, the Military Operational Medicine Research Program). He is a co-investigator, collaborator, or consultant on grants funded by several organizations, including, but not limited to, the Canadian Institute of Health Research, Alcohol Beverage Medical Research Council, Rehabilitation Research and Development (RR&D) Service of the US Department of Veterans Affairs, AstraZeneca Canada, Lundbeck Canada, and Pfizer Canada. He works part-time as a contractor, doing TBI in the military research, for the Defense and Veterans Brain Injury Center.

Serial assessment with WAIS-IV and WMS-IV.

Abstract: Clinicians frequently evaluate patients’ cognitive functioning over time. Patients may be re-evaluated to track cognitive decline associated with a degenerative disease, to aid in treatment planning, to identify medication effects on cognition, or to evaluate a change in cognitive status for diagnostic purposes. Comparing performance across time is complex and requires the clinician to consider multiple cognitive, statistical, and environmental factors. Using a simple heuristic (e.g., a change of one standard deviation between evaluations) can result in under- or over-estimation of a change in cognitive status. Applying appropriate statistical models helps the clinician control for practice effects, regression to the mean, and their interaction with characteristics of the individual (e.g., age and initial ability level). In this chapter, multiple regression techniques are applied to WAIS–IV and WMS–IV retest data to predict expected change in performance in healthy adults. The equations are derived for retesting with the same edition (i.e., WAIS–IV/WAIS–IV) and retesting with a different edition (i.e., WAIS–III/WAIS–IV, WISC–IV/WAIS–IV). The chapter describes the regression models and the use of comparison statistics for evaluating meaningful test score change (i.e., statistical significance and base rates). Challenges and limitations in identifying meaningful change in cognitive functioning are discussed.