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Associate Professor
UPMC Department of Orthopaedic Surgery
UPMC Department of Neurological Surgery
Director
UPMC Sports Medicine Concussion Program
Prognosticating Protracted
Recoveries from Sports
Concussion: What are we
Learning?
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.
Disclosure Statement
C o p y r i g h t © 2 0 1 1
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
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Recovery
from Sports
Concussion:
How long
does it Take?
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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
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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)
0
10
20
30
40
50
60
70
80
90
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 38 40+
All Athletes No Previous Concussions 1 or More Previous Concussions
N=134 High School
Male Football Athletes
WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5
40% RECOVERED
60% RECOVERED
80% RECOVERED
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Prognosticating Protracted Recovery
Following Sports Concussion:
What are we Learning?
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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….
Show Video
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Which 0n-Field Symptoms Predict
Protracted Recovery?
Lau B, Kontos A, Lovell MR, Collins MW.
AJSM.Vol. 39(11):2311-18; 2011
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 Symptoms Increase Risk of
Post Concussion Syndrome in High School Football Players?
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**p<.01
Which On-Field Markers/Symptoms Predict 3 or More Week
Recovery from MTBI In High School Football Players
Lau, Kontos, Collins, Lovell , AJSM 2011
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.
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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?
On-Field Symptom Summary
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Which Subacute
Symptoms
Predict Protracted
Recovery?
Lau B, Lovell MR, Collins MW; Pardini J;
CJSM 2009 (3):216-21
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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
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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)
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0
0.5
1
1.5
2
FOGGY DIFF CONC VOMIT DIZZY
NAUSEA HEADACHE SLOWNESS BALANCE
LIGHT SENS NOISE SENS NUMBNESS
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.
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• More emotional
• Sadness
• Nervousness
• Irritability
• Attention Problems
• Memory dysfunction
• “Fogginess”
• Fatigue
• Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
• Headaches
• Visual Problems
• Dizziness
• Noise/Light Sensitivity
• Nausea
Factor Analysis,
Post-Concussion
Symptom Scale (Pardini, Lovell, Collins
et al. 2004)
N=327, High School
and University
Athletes Within
7 Days of Concussion
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*Symptoms with the largest contributions to differences between “quick” and “protracted” recovery in each symptom factor.
Variables Classification Z-Score (Simple vs. Complex)
Fogginess Cognitive 4.3* Difficulty Concentrating Cognitive 2.46
Vomit Migraine 2.391* Dizziness Migraine 2.09
Nausea Migraine 1.96
Headache Migraine 1.71
Slowness Cognitive 1.53
Balance Migraine 1.53
Light Sensitivity Migraine 1.52
Noise Sensitivity Migraine 1.52
Numbness Migraine 1.46
Trouble Sleeping
Sleep
1.231* Visual Problems Migraine 0.97
Difficulty Remembering Cognitive 0.93
Sleeping Less Sleep .52
Drowsiness Cognitive 0.5
Fatigue Cognitive 0.48
Emotional Neuropsychiatric 0.37* Irritability Neuropsychiatric 0.3
Sadness Neuropsychiatric 0.09
Nervousness Neuropsychiatric -0.03
Sleeping More Cognitive -0.05
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Testing yields summary
composite scores for:
- Verbal Memory
- Visual Memory
- Reaction Time
- Visual Motor Speed
Computerized NP
Summary Scores
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-1
-0.8
-0.6
-0.4
-0.2
0
REACTION TIME VISUAL MEMORY
PROCESSING SPEED VERBAL MEMORY
NEUROCOGNITIVE PREDICTORS OF PROTRACTED
RECOVERY (Greater than 10 days to Recovery)
Effect Sizes compare quick recovery to protracted
recovery groups. (Cohen’s D)
D=.838
(Large)
D=.663
(Medium)
D=.466
(Medium)
D=.221
(Small) Deficit in
Reaction
Time
Best
Predicts
Protracted
Recovery
N = 108 p <.001
p<.001
p<.01
p<.05
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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
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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
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
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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 – 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
95% CI
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
Kontos AP, Elbin RJ, Simensky S, French J, Collins MW; In preparation..
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
Visual Memory
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)
PTM =
Post-Traumatic
Migraine ImPACT
Reaction Time
Raw Score
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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
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Utilizing Sub-Acute
Neurocognitive Test
Data to Determine
Prognosis
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CURRENTLY AVAILABLE PROGRAMS
Cogsport
Headminders (CRI)
ANAM
CNS Vital Signs
ImPACT
Computer-Based Neurocognitive Testing
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Schatz P, Pardini J, Lovell MR, Collins MW. Archives of Clinical Neuropsychology 2005:21;91-99.
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)
Sensitivity and Specificity of Computerized Neurocognitive
Testing in Classifying Athletes with Concussion
N = 138 controls/
concussed athletes
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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 Sub-
Cluster 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.
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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.
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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.
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Cutoff Values of ImPACT Neurocognitive Scores
at 2 Days Post Injury That Predict Protracted
Recovery
Sensitivity is defined as the ability of the cutoff to accurately identify
protracted recovery (Mean Recovery Time = 1 month) in an athlete.
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
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
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.
Iverson G. CJSM; 2008
Predicting Quick versus Protracted Recovery from
Sports mTBI
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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 utilized-
13.6% vs 32.9% (Meehan et al, AJSM, 2010).
Other Recent Peer Reviewed Research
Examining Neurocognitive Testing
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
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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
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The Role of Vestibular-Ocular Screening in the Assessment and Rehabilitation of
Sports Concussion
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The UPMC Sports Concussion Program
Department of Orthopaedic Surgery
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UPMC Concussion
Program
(Neuropsych)
Emergency Departments
Pediatric Practices
ATC from Contracted
Schools
Primary Care Physicians
Parents
/Schools Parents / School
Orthopaedic
Surgery
Neuro
Radiology
Vestibular /
Physical
Therapy
PM & R
Neuro
Surgery
The UPMC Sports Concussion Program
C o p y r i g h t © 2 0 1 1
PMR, Sports Med, Neurology, Pediatrics, Ortho, etc.
Emergency Departments
Pediatric Practices
ATC from Contracted
Schools
Primary Care Physicians
Parents
/Schools Parents / School
Neuropsych
Neuro
Radiology
Vestibular /
Physical
Therapy
Orthopaedic
Surgery
Neuro
Surgery
Sports Concussion / mTBI Clinic
C o p y r i g h t © 2 0 1 1
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.
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• 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
Vestibular-Ocular Screening
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Injury
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Vestibular Screening
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Domain Symptoms Main Environmental
Triggers Quote from Patients
Saccadic Eye Movements-
Vertical and Horizontal Headache, Fatigue,
Difficulty
concentrating
Computer Work,
Reading, Watching
Action Movies, Video
Games
“Its like my eyes are playing a slow game of
ping pong”
Gaze Stability-Vertical and
Horizontal Fogginess, Headache,
Fatigue, Dizzy, Anxiety Note Taking, Busy
Environments, Hallways, Running, Gymnasiums,
Busy Weightrooms
“It feels like I am outside myself, one –step behind, and the world is in slow
motion”
Ocular Convergence
(Convergence Insufficiency) Headache (frontal),
Fatigue, Irritability Reading, Computer Work,
Texting, Math and Chemistry,
“I feel like two fat men with two fat asses are
sitting on my eyes”
VOR Cancellation Nausea, Headache,
Fogginess, Fatigue,
Depersonalization,
Anxiety
Car Rides,
Supermarkets, Busy
Environments, Wide
Open Spaces
“While at the mall, I feel like I am looking out the side window of a high-
speed car…I just want to get out of there and it
freaks me out”
Vestibular-Ocular Screening
Expected Symptoms/Environmental Triggers
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Thank You Micky Collins, Ph.D.
412-432-3668 (Direct) or 412-432-3681 (Secretary)
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Interview
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Utilizing Subacute
Neurocognitive Test
Data to Determine
Prognosis
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• 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
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
What is Sensitivity/Specificity of ImPACT Cognitive
and Symptom Scores in Predicting Protracted Recovery?
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)
• More emotional
• Sadness
• Nervousness
• Irritability
• Attention Problems
• Memory dysfunction
• “Fogginess”
• Fatigue
• Cognitive slowing
• Difficulty falling asleep
• Sleeping less than usual
• Headaches
• Visual Problems
• Dizziness
• Noise/Light Sensitivity
• Nausea
Factor Analysis,
Post-Concussion
Symptom Scale (Pardini, Lovell, Collins
et al. 2004)
N=327, High School
and University
Athletes Within
7 Days of Concussion
C o p y r i g h t © 2 0 1 1
ImPACT yields
composite scores for:
- Verbal Memory
- Visual Memory
- Reaction Time
- Visual Motor Speed
Composite Scores
Variables Assessed at 2 Days Post Injury
PCSS Total Score Four Symptom
Clusters from Factor
Analysis of PCSS
Four Neurocognitive
Composite Scores
from ImPACT
22 items from
ImPACT PCSS
Migraine Cluster Verbal Memory
Cognitive Cluster Visual Memory
Neuropsychiatric
Cluster
Visual-Motor Speed (i.e. Processing Speed)
Sleep Cluster Reaction Time
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
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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
Predicting Outcomes Following Sports
MTBI: Construct Definitions
Sensitivity Ability of variables in discriminant function
analysis (DFA) to identify athletes, at 2 days post-
injury, 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%
Lau B, Collins MW, Lovell M. American J Sports Med, 2011
Migraine Cluster = Headache, Dizzy, Nausea, Vision changes, Photo/phonophobia
ImPACT = Reaction Time, Verbal Memory, Visual Memory
C o p y r i g h t © 2 0 1 1
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 Sub-
Cluster 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.
Which
Constitutional
Risk Factors and
Symptom Profiles
Predict Post
Concussion
Syndrome?
- Athletes with on-field retrograde amnesia were 10.0x
more likely to have “poor” outcome at 3 days post-
concussion
- Athletes with on-field anterograde amnesia were 4.2x
more likely to have “poor” outcome at 3 days post-
concussion
- Brief LOC not predictive of outcome
On-Field Markers Summary Statistical Odds Ratios
Collins, Iverson, Lovell, et al.; Clinical J Sport Med, 2003
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
On-Field Predictors Summary
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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)
Use of Computerized Neurocognitive Testing
In High School Athletes (Meehan et al, 2011)
C o p y r i g h t © 2 0 1 1
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
ImPACT
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
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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
Extensive data published on reliability, validity, sensitivity/specificity of test
ImPACT Computerized Neurocognitive Testing
Comparison of Recovery for PTM, Headache, No Headache/PTM groups
(χ2= 9.05, p= .009, n= 97)
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Variable Area Under Curve P-Value
*Migraine Symptom Cluster 0.66 0.01
*Cognitive Symptom Cluster 0.61 0.04
†Visual Memory 0.66 0.01
†Processing Speed 0.63 0.02
*Reaction Time 0.63 0.02
†Verbal Memory 0.45 0.39
*Sleep Symptom Cluster 0.55 0.41
*Neuropsychiatric Symptom Cluster 0.53 0.61
Table 3:
ROC Area Under Curve and P-values for
Symptom Clusters and Neurocognitive Scores:
*=Variables where increasing values indicate poorer performance
†=Variables where decreasing values indicate poorer performance
Lau B, Collins MW, Lovell MR. Neurosurgery 2012.
