Diagnostic Utility of Attention Measures in Postconcussion Syndrome

Abstract

Neuropsychological evaluation may be of particular relevance in the detection of subtle cognitive impairments after mild traumatic brain injury (MTBI), including the subgroup of MTBI patients with a persistent postconcussion syndrome (PCS). Attention measures may be the most sensitive indicators of dysfunction associated with MTBI; however, previous studies have typically relied on the analysis of overall group differences, which may not reflect the diagnostic accuracy of attention measures when applied to individuals with MTBI. In the present study, subjects with persistent symptoms at least 3 months following a mild traumatic brain injury were compared with a sample of community living, normal control subjects in order to evaluate the sensitivity, specificity, and diagnostic accuracy of attention measures. Patients with PCS, screened with conservative inclusion and exclusion criteria, and a matched normal control group were administered six clinical tests of attention: Digit Span, Trail Making Test, Part A and Part B, Stroop Color-Word Test, Continuous Performance Test of Attention (CPTA), Paced Auditory Serial Addition Test (PASAT), and Ruff 2 & 7 Selective Attention Test. Consistent with prior research, these measures exhibited a wide range of sensitivity and specificity to possible cognitive impairment among patients. Attention measures may be the most sensitive indicators of dysfunction associated with PCS. Measures with high specificity (e.g., Stroop Color, and 2 & 7 Processing Speed) were shown to have strong positive predictive value, while measures with high sensitivity (e.g., CPTA) demonstrated strong negative predictive value for diagnosing PCS. Examination of the Odds Ratios indicated that measures assessing processing speed had a reliable, positive association with PCS, while measures without a processing speed component did not. Implications for making informed clinical decisions are discussed.

Mild Traumatic Brain Injury: Longitudinal Regional Brain Volume Changes

“…The rAC is actively implicated in cognitive control domains (56) such as selective attention processing and working memory (48,49). These are cognitive domains that have previously been found to be dysfunctional in PCS (57,58). Consistent with the functional role of the rAC, we found that rAC WM volume changes in patients with MTBI correlated significantly with scores on the CVLT, a test of verbal memory, learning, and encoding, as well as with scores on the PASAT, a test of attention.…”

Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury

“…However, mDSM-IV (COG) criteria diagnosed fewer control participants with PCS, and there were higher cognitive failures and more cognitive RPQ items reported by those with mTBI than those without. This suggests that cognitive deficit could be an important distinguishing factor for PCS between those with concussion and healthy non brain injured populations [42,80]. Subjective criteria may not be specific enough to diagnose PCS after mTBI.…”

Call for an Integrative and Multi-Disciplinary Approach to Traumatic Brain Injury (TBI)

“…With Trail Making tests that require complex attention and cognitive flexibility, completion times increase with increasing severity of head injury (Dikmen et al, 1995) and are associated with diffuse axonal injury (Felmingham et al, 2004), but they may not be sufficiently sensitive measure in mild brain injury (Cicerone & Azulay, 2002). Scores from both Trails A and Trails B contributed to the prediction of degree of independent living of moderate and severe TBI patients, with shorter completion times associated with greater likelihood of independent living (Acker & Davis, 1989).…”

“…In addition to differentiating TBI patients from controls, performance on the SDMT test differentiated between early versus late recovery (Bate et al, 2001) and was sensitive to the effects of diffuse axonal injury (Felmingham, Baguley, & Green, 2004), and predicted changes in the daily functioning 5 years after TBI (Hammond, Hart, Bushnik, Corrigan, & Sasser, 2004). TBI patients have slower completion times on the subtests of the Stroop, although they do not consistently show disproportionate difficulty with the interference condition (Ponsford & Kinsella, 1992;Felmingham et al, 2004) and some have questioned the sensitivity of the Stroop Interference test as a diagnostic tool in mild TBI (Cicerone & Azulay, 2002). Measures of auditory attention span, as the Digits Forward test, tend to be more sensitive to left versus right hemisphere damage and performance on this test correlates with the number of concussions or brain injuries (Matser, Kessels, Lezak, Jordan, & Troost, 1999).…”

“…Such cross sectional study designs have been used to explore variables as gender and the number of sport concussions (Cantu, Guskiewicz, & Register-Mihalik, 2010;Frommer et al, 2011;Matser et al, 1999), cognitive deficits in persistent postconcussive syndrome (e.g. Cicerone & Azulay, 2002) and psychiatric comorbidities of PTSD and depression with moderate and severe TBI (Romesser et al, 2011;Zatzick et al, 2010). In comparing 812 sports concussions across nine competitive sports, male athletes were more likely to report symptoms of amnesia, confusion and disorientation, while female athletes reported more drowsiness and sensitivity to noise than did males (Frommer et al, 2011).…”