Professional Documents
Culture Documents
Postconcussion Syndrome:
The New Evidence Base for
Diagnosis and Treatment
Michael McCrea, PhD, ABPP-CN
Neuroscience Center, Waukesha Memorial Hospital
Department of Neurology, Medical College of Wisconsin
Neurosurgery:
Neurology:
Sports Medicine:
Epidemiology:
Part 1:
The TBI Landscape
1. Epidemiology and impact of allseverity TBI
2. Zeroing in on MTBI: Epi and Impact
3. Challenges in Defining & Diagnosing
MTBI
4. Advances in MTBI research
methodologies
5. Top 10 Conclusions
Challenges in
Defining & Diagnosing MTBI
Classifying TBI severity an imperfect
science
Varied emphasis on acute injury
characteristics
Limitations of traditional methods
(GCS)
Limited reliability, validity, predictive
power of newer classification methods
Numerous case and administrative
definitions
2005
Mild
Severity Classification
Moderate
13-15
9-12
3-8
Loss of Consciousness
< 20 minutes
20 min 36 hours
> 36 hours
Posttraumatic Amnesia
< 24 hours
1-7 days
> 7 days
Severe
MTBI Definitions
ACRM
GCS
13-15
CDC
WHO
DVBIC
AAN
CSG
Cantu
13-15
LOC
< 30
PTA
< 24 hours
Other
< 30
< 24 hours
AMS, amnesia,
symptoms
< 30
< 24 hours
At least 1 symptom;
other causes r/o
Interpretation of
findings on acute
effects, recovery,
treatment response,
outcome, prevalence
of disability after
MTBI
Too Restrictive?
Too Inclusive?
Under-report true
incidence, impact
and disability of MTBI
and PCS;
Over-report true
incidence, impact
and disability of MTBI
and PCS;
Too Inclusive?
Unnecessary
resource utilization;
inaccurate Dx that
does not recognize
true cause and
prescribe best
treatment
TBI Prognosis:
Some Things Are Crystal Clear
Injury Severity is Strongest
Predictor of Recovery
after moderate and severe
TBI
Acute MTBI
Research Limitations
Recovery: How long should it take to recovery after MTBI? What is the expected natural
course of this injury?
Prognosis: What are the acute and subacute predictors of positive and negative outcomes
after MTBI?
Treatment: Given all this, what approach to treatment gives my patient the best chance for
recovery?
Outcome: What are the best methods to assess recovery and functional outcome after MTBI?
Streaker Suffers
Concussion
If you're planning to streak at an NHL game, at least wear a pair of
skates. In the third period of Thursday's Bruins-Flames game in
Calgary, a male streaker (wearing only red socks and a smile)
scaled the low glass near the scorers table and jumped onto the
playing surface. The naked stranger quickly lost his
Causes of TBI
Other
43%
MVA 28%
Sports 20%
Assaults
9%
Biomechanics of MTBI:
Establishing a minimal biomechanical threshold
Accelerometry Instrumentation
Neurophysiology of MTBI
Diffuse Axonal Injury (DAI) prominent in
moderate and severe TBI, not in MTBI
The pathophysiology of MTBI renders neurons
dysfunctional, but not destroyed
+/-
Comment
CT
Structural
R/O neurosurgerical
emergency; poor sensitivity
to smaller lesions
5-20% MTBI
positive
MRI
Structural
10-40%
positive
DTI
Mixed
samples TBI
severity
MTI/
MSI
Magnetic Transfer/Magnetic
Source Imaging; improvement
from T1, T2 weighted imaging;
combines MEG with MR
Suggested sensitivity in
MTBI; specificity unclear
Limited data
to evaluate
MRS
Sensitive, non-specific;
Weak association w/ injury
assessment, outcome
Limited data
to evaluate
+/-
fMRI
Functional imaging of
neuronal activation
(and dysfunction)
Better temporal/spatial
resolution and better brain
mapping than others; data
on neurophysiological
effects, recovery
SPECT
Functional imaging of
regional blood flow
PET
Functional imaging of
blood flow, oxygen,
glucose metabolism
(different from SPECT)
Comment
Largest
literature of
any; guides
natural hx
research; rehab
applications
Part 3:
What is the true natural history of MTBI?
Part 3:
Natural History of MTBI
1.
2.
3.
4.
5.
6.
7.
8.
1960's
1970's
1980's
1990's
2000's
Neuropsychological
Research Supported by: NCAA, NOCSAE, NAN, NFL Charities, NFHS, Green Bay Packers Foundation,
WMH Foundation, MCW Functional Imaging Research Center
Investigators hold no relevant financial interest or conflict in the research methods, materials, or findings
Project SL
CDC
25
20
124
4,251
3,279
9,094
196
87
375
93.2%
6.8%
82.1%
17.9%
80.7%
9.3%
LOC
6.8%
17.9%
9.3%
PTA
19.1%
37.3%
21.9%
RGA
7.4%
29.9%
17.3%
No LOC/PTA
77.8%
49.1%
64.5%
84%
98%
80%
Teams
Player Seasons
Concussions
% Complete Protocol
Methods
Main Outcome Measures: Concussion Symptom Inventory
(CSI), Standardized Assessment of Concussion (SAC), Balance Error
Scoring System (BESS), Neuropsychological Test Battery, (fMRI)
Time
of
Injury
GSC
SAC
BESS
PostGame/
Day 1
PostPractice
GSC
GSC
SAC
SAC
BESS
BESS
NP Test
fMRI
Day 2
GSC
SAC
BESS
NP Test
Day 3
GSC
SAC
BESS
Day 5
GSC
SAC
BESS
Day 6/7
GSC
SAC
BESS
NP Test
Neuropsychological testing on days 1, 8, & 45 for HS, days 2, 7, and 90 for college; fMRI in high school only
Day
45/90
GSC
SAC
BESS
NP Test
fMRI
Immediate Symptoms
100
90
80
70
60
50
40
30
20
10
0
Day 3 Symptoms
100
90
80
70
60
50
40
30
20
10
0
Day 7 Symptoms
100
90
80
70
60
50
40
30
20
10
0
Orientation:
Day, Month, Date,
Year, Time
Immediate
Memory:
Repeated List
Learning Paradigm
Neurologic
Exam:
Strength, Sensation,
Coordination
Record LOC, PTA
Concentration:
Digits Backward
Months Backward
Delayed Recall:
Word List Recall
Exertional
Maneuvers:
Provocative
conditions
/5
/15
/5
/5
Day 1-2
Day 6-7
Day 45-90
G.E.E MODELING*
Day 1-2
Day 6-7
Day 45-90
Summary
39 studies, 48 MTBI (n=1716) vs.
control (n=1164) comparisons;
Moderate in overall cognitive
functioning <7 days post-injury
(d=.41)
Added Value of
Neuropsychological Testing
100
90
Specificity
80
NP Testing
Sensitivity
70
Brief Battery
60
50
Neuropsychological Testing:
40
30
20
10
Neurocognitive Impairment:
0
CC
PG
D1 D2 D3 D5
Assessment Point
D7
Day 7
SxImpaired
Controls
Impaired
SxImpaired
Controls
Impaired
(n=68)
(n=56)
(n=85)
(n=56)
BESS
37%
9%
8%
7%
SAC
16%
7%
7%
7%
NP Battery
15%
8%
16%
9%
(true +)
(false +)
(true +)
(false +)
NP Net Gain
7% Detection
7% Detection
(TP-FP)
specificity 89.4% < 72 hr post; 85% correctly classified; no report of cognitive predictor
independent of symptoms
Van Kampen (2006): NP testing increased sensitivity from 64% to 83% over
symptoms alone; 30% false + rate
Project SL
CDC
196
87
375
93.2%
6.8%
82.1%
17.9%
80.7%
9.3%
LOC
6.8%
17.9%
9.3%
PTA
19.1%
37.3%
21.9%
RGA
7.4%
29.9%
17.3%
No LOC/PTA
77.8%
49.1%
64.5%
84%
98%
80%
Concussions
% Complete Protocol
35
30
25
20
15
10
5
0
BL
Control
CC
PG
D1
No PTA/LOC
D2
D3
D5
PTA/No LOC
D6
D45
LOC+PTA
30
SACTotal Score
28
26
24
22
p < .001
20
BL
CC
Control
PG
D1
No PTA/LOC
D2
D3
D5
PTA/No LOC
D6
D45
LOC+PTA
Day 1-2
Day 6-7
Day 45-90
Day 1-2
Day 6-7
Day 45-90
Functional MRI
ADVANTAGES:
Non-invasive
Better spatial/temporal resolution
than PET/SPECT
No radiation exposure multiple
studies
More methodologically appropriate
for studying effects of treatment
and rehabilitation
MR technology access
Low cost compared to PET
Measuring Meaningful
Cerebral Change
Sternberg Task
Remember: 4 7 3 8
Load Dependent
Memory Scanning Task
Time
7
2.5 sec
5.0 sec
7.5 sec
Maintenance delay
10
15
20
seconds
25
Left Medial
Right Medial
Left
Right
Control
Concussed
Right Lateral
Z = -6
Z=9
Z = 21
Z = 36
Z = 47
Encoding Phase
Left SMA/PreSMA
P=1.5x10-5
vol=371 uL
alpha=0.05
0.8
Control
Injured
0.6
0.4
0.2
+ SE
1.0
0.8
Injured
Controls
0.6
0.4
0.2
0.0
Day 1
Day 45
Imaging Session
0.0
-0.2
1
Image Number
P=1.5x10-5
vol=371 uL
alpha=0.05
0.8
0.6
Control no loc
Control loc
Injured no loc
Injured loc
0.4
0.8
0.6
0.4
0.2
0.0
0
0.0
-0.2
Image Number
Z=9
L
L
Z = 21
Z = 36
Z = 47
R
R
Neuronal Activation
Acute Injury:
Brain injured sufficiently to dysregulate
consistent neuronal recruitment
(decreased fMRI activation)
Recovery/Rehabilitation:
Allows/facilitates recruitment of additional
neuronal resources to maintain functional
standard (increased functional activation)
15
30
45
Science of MTBI
Recovery
Clear, sound evidence
Kids: rapid recovery, no residual
cognitive, behavioral, academic
deficits
Adults: rapid symptom,
cognitive recovery; no
impairments 3-12 mos
Non-injury factors predict
persistent symptoms
30
Control
Symptom Severity
25
Concussion
20
15
10
Assessment Point
64% = SOME
12%=OFTEN
25
20
15
General male population
10
5
0
0-2
Survey N = 2,488
Depression N = 263
3-4
Number of Previous Concussions
5+
Cumulative Percentages
120
100
80
NFL
60
Normative
40
20
0
< 60
< 65
< 70
< 75
< 80
< 83
< 95
Age Cohorts
NFL Mean Age: 71.7 (7.62); Median: 74.0; Range: 52-83
Implications for
Rethinking Postconcussion
Syndrome
Part 4:
Implications for Rethinking
Postconcussion Syndrome
1.
2.
3.
4.
5.
6.
7.
8.
What is PCS?
ICD-10: F07.2 (part of class of disorders with a
What is PCS?
DSM-IV- proposed new category:
A. History of a head trauma that has caused significant concussion (loc, pta,
sz)
B. Evidence from neuropsychological testing of impaired attention or memory
C. Three or more occur shortly post-injury and persist for at least 3 months:
Headache
Dizziness
Irritability
Fatigue
Anxiety, depression, or emotional lability
Sleep disturbance
Personality change
Apathy
Dizziness
Irritability
Memory
problems
Conc.
problems
College
students1
36%
18%
36%
17%
42%
Chronic
pain2
80%
67%
49%
33%
63%
Depressed3 37%
20%
52%
25%
54%
PI
claimants
(non tbi)4
77%
41%
63%
46%
71%
mTBI5
42%
26%
28%
36%
25%
1. Sawchyn et al., 2000; 2. Radanov et al., 1992; 3.Trahan et al., 2001; 4. Dunn et al., 1995; 5. Ingebrigtsen et al., 1998
article)
145 consecutive mild TBI cases admitted to hospital in Belfast.
131 followed up at one year, 19 still reporting symptoms (14.5%)
8/19 involved in lawsuits, 6/19 suspected of malingering at 6 weeks postinjury (overlap of 5)
10/19 pts reporting at least one new symptom not endorsed 6 weeks postinjury
Age not related to duration of symptoms, but gender was (women more
likely to be symptomatic)
No controls (e.g., ortho injuries)
WHO Collaborating
Centre Task Force on Mild
Traumatic Brain Injury
Results of survey of nonsurgical interventions and cost
for mTBI (J Rehabil Med
2004):
Evidence that early intervention
can reduce long-term complaints,
and that this intervention need
not be intensive.
Neuropsychologys Response
AAN Position Statement: Where are neuropsychology
and rehabilitation psychology?
Military MTBI Task Force: Inter-organizational
collaboration between:
- APA Division 40
- APA Division 22
- American Academy of Clinical Neuropsychology
- National Academy of Neuropsychology
Contact Information
Michael McCrea, PhD, ABPP-CN
Neuropsychology Service
Waukesha Memorial Hospital
721 American Avenue, Suite 501
Waukesha Memorial Hospital
Waukesha, WI 53188
Office: 262-928-2156
Fax: 262-928-5580
Email: michael.mccrea@phci.org