Concussion Hits Hard:
Recovery from the Multiple Effects of Concussion:
Requires Interventions be based on an Appropriate Multi-modal Assessment
Although assessment of the patient who has suffered a concussion must be first carried out by a knowledgeable medical specialist the kind of multimodal assessment that can lead to successful interventions may be done by other professionals, including psychologists. Hospital assessments detect certain types of damage, such as sub-dural haematomas, but are unlikely to detect the cause of symptoms that the patient is experiencing. MRI, PET, and CAT scans often show no abnormality. In addition, traditional rehabilitation often meets the criteria of conservative do no harm but may do little to remedy the deficiencies caused by minimal to moderate injury.
The methodology for efficient and accurate assessment that can lead to effective intervention includes quantitative electroencephalogram (QEEG) and evoked potentials (ERP). These can reveal the effects of damage elicited by stretching and twisting of axons, called diffuse axonal injury (DAI). The evoked potentials are particularly important for reflecting brain speed. Traumatic brain injury (TBI) will often have a negative impact on the right and/or left insula in the cortex of the brain that, in turn, relates to changes in heart rate variability (HRV). Thus concussion assessment should measure QEEG, ERPs, HRV, and, using continuous performance tests (CPT), measure attention, impulsivity and variability of response time. This should be combined with neuropsychological testing, in particular for short and long term memory, attention span, impulsivity and questionnaires regarding medical health, depression, and anxiety. When available, balance assessment of vestibular function with a ‘force-plate’ can be helpful. All this is accomplished in a half-day assessment at the ADD Centre and Biofeedback Institute.
Most importantly, interventions that are based on these assessments have been highly successful at the Biofeedback Institute.
Additions to Assessment and Interventions Section of The Neurofeedback Book
Concussion / Mild Traumatic Brain Injury (TBI)
There is nothing “mild” about the impairments that result from a mild traumati brain injury (TBI) which is commonly called a concussion. A variety of neuropathological processes triggered by damage caused when the brain matter collides with the rough, ridged edges of the skull or when there is rapid acceleration/deceleration and/or quick rotation of the brain. A lack of objective pathognomic signs of concussion means that a physician’s diagnosis often rests on an athlete’s honest report of subjective symptoms (e.g., headache, irritability, fatigue, blurred vision) that are also common in the non-concussed population and known to vary day to day. As a result of the varying symptomology following concussions, currently employed tests used in concussion assessment, and when making return to play decisions for athletes, often give conflicting results. One-dimensional testing protocols have the potential to miss diagnosing a concussion if the tests are not sensitive to a particular individual’s symptoms. More advanced testing paradigms are needed that use a combination of testing modalities. Dr. James Thompson, (Ph.D. in Sports Psychology from Penn State University) did extensive research on concussion in varsity athletes for his doctoral dissertation and reached four overall conclusions. First, neuropsychological symptoms measured by paper and pencil tests resolve themselves more quickly than do postural or EEG changes. Second, there is a clear mismatch between subjects’ injury classifications when neuropsychological, postural and EEG testing paradigms are compared. Third, the use of a testing paradigm that combines the most sensitive tests from each modality appears to provide a more effective system for diagnostic and return to play measurements than does any one method alone. Fourth, low resolution electromagnetic tomography (LORETA) is a valid tool for assessing which cortical areas are affected after concussion. Based on his research, and that of others in this field, he has developed along with Dr. David Hagedorn (a psychologist who works with the US Navy), a method for the comprehensive measurement of brain functioning using the Brain Injury Assessment Tool (BIAT) plus computerized neuropsych. testing (www.Evokeneurscience.com) Biochemical testing of blood and urine can be added as deemed necessary.