Montana Psych Licensing Board Imposing Standards on VA (neuropsych related)

Therapist4Chnge

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This is something that has gotten some notice on a variety of listservs and thought it'd be worthwhile to discuss here.

...A state licensing board in Helena has barred a psychologist working for the VA at Fort Harrison from evaluating veterans for traumatic brain injuries.

The Montana Board of Psychologists ruled this month that Robert Bateen was not qualified to provide a neuropsychological assessment of Charles Gatlin, a University of Montana graduate student, and that he failed to provide an adequate standard of care. And it rejected Bateen’s contention that he was merely following VA policy. “Licensee has an independent professional obligation to ensure his work as a psychologist complies with the statutes and rules governing his license,” said the state licensing board.

*snip*

“Licensee is not a clinical neuropsychologist and is not qualified to provide neuropsychological services,” the state hearing board said. Although Bateen has completed the Traumatic Brain Injury Course and the CPEP Traumatic Brain Injury Examination TBI Combo, “none of the foregoing is sufficient education, training, or experience to qualify a clinical psychologist for the practice of neuropsychology. Licensee is not trained in neuropsychological assessment.”

More at: http://www.psychologytoday.com/blog/invisible-wounds/201409/state-imposes-its-standards-va

I'm hoping this leads to stricter standards and hopefully protection of the title, as this kind of stuff happens all of the time.
 

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I saw this as a good and bad situation for us. Yes, neuro assessment should be limited to properly trained individuals. And the RBANS is a terrible choice for this type of assessment. The bad is the C&P implications. First, the system is pretty screwed up as is, no debating that fact. Between the variability between assessments, lack of any assessment whatsoever, and the fact that raters usually have little or no medical training. Second, and more scary I think is the possibility that PVT/SVT performance could be attacked in these settings. Some places are already scared to use them considering the high failure rate in the VA settings, I think it only gets worse after this.
 

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very interesting, thanks for sharing.

I wonder if this will lead to any change in the VA, who does not have to listen to Montana at all. However, the license holder has to listen to their state licensing board. An interesting dilemma.
 
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My concern is where do we draw the line between a neuropsych and non-neuropsych? In my community, we have no neuropsychologists and my patients would have to drive 100's of miles and wait for about 6 months to see a neuropsychologist. I recently referred a therapy patient to another psychologist for a dementia eval. Should I not have? I am thinking I am pretty safe with learning disability evals, but sometimes the kid may have bumped their head a few times in the past. If I think that may have been a factor, then I will usually make a recommendation for neuropsych testing, but patients tend not to follow up and maybe I should not have tested at all once I find that out.
 
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erg923

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My concern is where do we draw the line between a neuropsych and non-neuropsych? In my community, we have no neuropsychologists and my patients would have to drive 100's of miles and wait for about 6 months to see a neuropsychologist. I recently referred a therapy patient to another psychologist for a dementia eval. Should I not have? I am thinking I am pretty safe with learning disability evals, but sometimes the kid may have bumped their head a few times in the past. If I think that may have been a factor, then I will usually make a recommendation for neuropsych testing, but patients tend not to follow up and maybe I should not have tested at all once I find that out.

There are no neuropsychologval tests, only neuropsycholgical interpetations of tests data. If one was to do this "neuropsychologival intepretation" of test data without training, one would likley be doing it "wrong." Is marginal npsych better than no npsych? I say no. Because if it misses something (which is real risk), well, whats was the point?
 
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WisNeuro

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My concern is where do we draw the line between a neuropsych and non-neuropsych? In my community, we have no neuropsychologists and my patients would have to drive 100's of miles and wait for about 6 months to see a neuropsychologist. I recently referred a therapy patient to another psychologist for a dementia eval. Should I not have? I am thinking I am pretty safe with learning disability evals, but sometimes the kid may have bumped their head a few times in the past. If I think that may have been a factor, then I will usually make a recommendation for neuropsych testing, but patients tend not to follow up and maybe I should not have tested at all once I find that out.

If it's a couple minor bumps, no testing is needed. You'll get no more additional information outside of what you got from interview. In more complicated cases, I agree with erg about no eval is better than a non-nuanced eval. Is something is wrong and it is missed, the person may never receive an appropriate follow-up and be lulled into a false sense of complacency.
 

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Do you want a person to been tested…or do you want them to be tested right? Access to care is an ongoing issue for much of healthcare, and neuropsych is just another one of those areas. However, providing an assessment that is not sufficient and/or done incorrectly can be very costly because of improper treatment (via the incorrect recommendations) and often harm the patient (improper medication for the wrong dx). I know if it was my family member I'd want them to see a qualified person, even if it take 4-6 months and I have to drive them 100s of mile to make that happen.
 

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I would say that screening people (MMSE, MoCA, RBANS) would be ok, but if it's a complicated issue, or they need a more comprehensive eval, refer out. Really depends on the situation.
 
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I would say that screening people (MMSE, MoCA, RBANS) would be ok, but if it's a complicated issue, or they need a more comprehensive eval, refer out. Really depends on the situation.
Wasn't part of the problem his use of the RBANS? I myself wouldn't administer that test since I am not familiar with it. Also, from my reading of the article, he should not have been doing an assessment for a patient with a TBI despite having some additional education in that area. I wonder if he made a recommendation for further testing?
Also, if you require a neuropsychologist conduct every eval to determine compensation for a patient with suspected TBI, I imagine the waiting list is going to increase. Of course, that could be a good thing to increase the standards and level of training required, but then again the VA might start hiring psychometricians to do these evals and go completely around the Board of Psychology's jurisdiction.
 

Therapist4Chnge

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Also, if you require a neuropsychologist conduct every eval to determine compensation for a patient with suspected TBI, I imagine the waiting list is going to increase. Of course, that could be a good thing to increase the standards and level of training required, but then again the VA might start hiring psychometricians to do these evals and go completely around the Board of Psychology's jurisdiction.

If a loved one needed a heart transplant would you let the surgical tech step in bc the hospital didn't employ enough cardiac surgeons? Would you let a general surgeon 'take a stab at it' because they are a surgeon and all surgeons are the same, right? Should that surgeon do the surgery because that is "policy" at the hospital?
 
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If a loved one needed a heart transplant would you let the surgical tech step in bc the hospital didn't employ enough cardiac surgeons? Would you let a general surgeon 'take a stab at it' because they are a surgeon and all surgeons are the same, right? Should that surgeon do the surgery because that is "policy" at the hospital?
My father went to see a neuropsychologist based on my recommendation so you are preaching to the choir. There is a move towards lower standards in throughout healthcare in my opinion. I am just pointing out some of the realities as I experience them, if I were to say no to enough assessments eventually my employer would look for someone willing to do them and he would find that a MA level person would do them for less and without complaint. This has already happened with substituting a PMHNP for a psychiatrist. The VA is a strong supporter of psychologists and has consistently supported higher standards in our field and I think we should work with them more than against them which is my concern on this issue. In other words, I don't know if the decision was upholding higher standards or unreasonable standards. If the consensus of practicing neuropsychologists is that the determination of disability and compensation in a TBI should be conducted by a neuropsychologist, then that does become a reasonable standard, then I would defer to that judgement.
 
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Therapist4Chnge

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The only real rub I see with stricter standards is how to account for rehabilitation psychologists who are also fellowship trained and often times are in a much better position to Dx TBI, etc. I'm hoping the Baltimore Conference standards can bridge this gap (in the same way the Houston Guidelines did for neuropsych), though that process is ongoing.
 
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I really wonder how much experience the Montana BOP has working with Veterans, and how their presentation of TBI along with the cluster of co-morbid factors that are likely the true cause of neurocognitive difficulties (e.g., ptsd, depression, pain, sleep, substance use) vastly differs from civilian injuries. Seriously, a Veteran with a "low average" score who also has a PTSD rating...go figure. I also wonder why the Veteran did not get an early medical board evaluation if his difficulties were so severe to warrant a 70% SC rating. Regardless, I feel that part of the problem is that C&P folks do not have the time to spend with patients that would occur during a typical outpatient neuropsychological assessment, so they need to greatly reduce whatever testing they may do, sometimes not a whole lot more than performance validity measures. It would be a misuse I feel of resources to have a really well trained neuropsychologist doing solely C&Ps, as the majority of service connection ratings are non-neurologic in nature. For the more complex cases, C&P folks can and do pull from CPSE chart records, so a patient can get a more through outpatient assessment if needed. Also, Veterans usually go through several steps of evaluation before psych assessment for even endorsement of the mildest of symptoms, and it is unknown what sort of data was available in the second level TBI evaluation/neurology notes to aid in modifying a service connection rating. Also, are all patients now going to claim significant impairments when they have a low average score? Regarding the latter, I have seen providers use 25-75%ile as average, and 16-84%ile as average, both of which can be argued for and against. Research has been showing that even in individuals with high premorbid baselines (e.g., high average, superior), it is not uncommon to obtain average scores on various neuropsychological measures. No one is going to perform completely consistently across the board.
On a side note to another post, all joking aside, if I thought a patient may have dementia, I would definitely not want them driving, let alone 100 miles:)
 

erg923

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We have 2 legit VA neuropsychologists doing C&Ps full-time in our associated IDEDS clinic.
 
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I really wonder how much experience the Montana BOP has working with Veterans, and how their presentation of TBI along with the cluster of co-morbid factors that are likely the true cause of neurocognitive difficulties (e.g., ptsd, depression, pain, sleep, substance use) vastly differs from civilian injuries. Seriously, a Veteran with a "low average" score who also has a PTSD rating...go figure. I also wonder why the Veteran did not get an early medical board evaluation if his difficulties were so severe to warrant a 70% SC rating. Regardless, I feel that part of the problem is that C&P folks do not have the time to spend with patients that would occur during a typical outpatient neuropsychological assessment, so they need to greatly reduce whatever testing they may do, sometimes not a whole lot more than performance validity measures. It would be a misuse I feel of resources to have a really well trained neuropsychologist doing solely C&Ps, as the majority of service connection ratings are non-neurologic in nature. For the more complex cases, C&P folks can and do pull from CPSE chart records, so a patient can get a more through outpatient assessment if needed. Also, Veterans usually go through several steps of evaluation before psych assessment for even endorsement of the mildest of symptoms, and it is unknown what sort of data was available in the second level TBI evaluation/neurology notes to aid in modifying a service connection rating. Also, are all patients now going to claim significant impairments when they have a low average score? Regarding the latter, I have seen providers use 25-75%ile as average, and 16-84%ile as average, both of which can be argued for and against. Research has been showing that even in individuals with high premorbid baselines (e.g., high average, superior), it is not uncommon to obtain average scores on various neuropsychological measures. No one is going to perform completely consistently across the board.
On a side note to another post, all joking aside, if I thought a patient may have dementia, I would definitely not want them driving, let alone 100 miles:)
Family members do the driving even to our clinic. Of course, how the patient was able to get to our clinic is part of an assessment. Also, from reading your narrative, I would actually conclude that a neuropsychologist (and for me, whenever I use that term I mean board certified) should be conducting these evals because of the complexity of assessing pre-morbid function and normative variation of abilities on measures.
 

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Wasn't part of the problem his use of the RBANS? I myself wouldn't administer that test since I am not familiar with it. Also, from my reading of the article, he should not have been doing an assessment for a patient with a TBI despite having some additional education in that area. I wonder if he made a recommendation for further testing?
Also, if you require a neuropsychologist conduct every eval to determine compensation for a patient with suspected TBI, I imagine the waiting list is going to increase. Of course, that could be a good thing to increase the standards and level of training required, but then again the VA might start hiring psychometricians to do these evals and go completely around the Board of Psychology's jurisdiction.

I suspect, and have heard some backchannel chatter, that there is much more to this than just the use of RBANS. In a clinical context, this is not an appropriate use of the RBANS. Also, testing is not required to "diagnose" mild TBI. 99.99% return to normal functioning. The "miserable minority" is a myth that has persisted due to litigation. Read the rebuttals of the work, it has been empirically shredded to bits.
 

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I'm really curious if, how, and when effort measures were used in this case. There are some pretty large differences in the use of effort measures in the VA system when I was in training. I'm not sure if they have an official standard now, but that is a consideration if there is/was an issue with any of the data from one or more of the evaluations.
 

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I too am curious about the impact of this case on practice. On the one hand, I agree that stricter standards are a good thing for complex issues such as PTSD/tbi dual dx and C&P evals. However, where are we drawing the line, as smalltownpsych mentions, between psychological and neuropsych evaluations and what are we declaring as proper training given the lack of consistent standards till recently. Coming from the LTC and subacute rehab world, social workers and SLPs are often giving brief evals to determine cognition. I am not fellowship trained, but I have strong assessment background and that is a rarity among my colleagues. So, where do strict standards turn into lack of access and, ultimately, irrelevancy in real world clinical work. While I agree that this case seems improper, is it not a bit silly to blankety limit those psychologists with training while those with much less training are free to continue to do so?
 

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I'm really curious if, how, and when effort measures were used in this case. There are some pretty large differences in the use of effort measures in the VA system when I was in training. I'm not sure if they have an official standard now, but that is a consideration if there is/was an issue with any of the data from one or more of the evaluations.


That is an interesting question. When I trained at the VA, these measure would often lead to findings of insufficient effort in vets with co-morbid PTSD and chronic sleep issues. It seemed to me that some of the measures were too sensitive given the additional issues and cost people some connectivity.
 

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That is an interesting question. When I trained at the VA, these measure would often lead to findings of insufficient effort in vets with co-morbid PTSD and chronic sleep issues. It seemed to me that some of the measures were too sensitive given the additional issues and cost people some connectivity.

I don't know that I'd say they're too sensitive so much as they're picking up on systemic issues that aren't the direct result of PTSD or poor sleep. Just looking at some initial analyses I ran and have seen run, neither sleep nor PTSD seems to significantly affect cognition in an objective sense.

As for social workers and SLPs conducting even brief cognitive evals--honestly, I'm not supportive of it due to the lack of training in those areas and subsequent potential for over/under-pathologizing.
 

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That is an interesting question. When I trained at the VA, these measure would often lead to findings of insufficient effort in vets with co-morbid PTSD and chronic sleep issues. It seemed to me that some of the measures were too sensitive given the additional issues and cost people some connectivity.

If someone missing their entire right hemisphere, or patients with severe dementia that are institutionalized with 24 round the clock care can score a certain number on these tests, chronic sleep problems don't cause chance level performance. Also, the PTSD causing cognitive problems literature is severely flawed. It occurs almost exclusively within a secondary gain context and teh vast majority of it doesn't account for effort. The studies that have accounted for effort have uniformly found no cognitive differences. The additional issues don't cause demonstrable differences on PVT's.
 

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If someone missing their entire right hemisphere, or patients with severe dementia that are institutionalized with 24 round the clock care can score a certain number on these tests, chronic sleep problems don't cause chance level performance. Also, the PTSD causing cognitive problems literature is severely flawed. It occurs almost exclusively within a secondary gain context and teh vast majority of it doesn't account for effort. The studies that have accounted for effort have uniformly found no cognitive differences. The additional issues don't cause demonstrable differences on PVT's.

I should be more clear. I am not questioning the validity of malingering/ effort in general, but rather a specific test. When when every person given a TOMM passes and nearly every person given a Green's Word-Memory fails, I have to question that test. Granted, N=~25 in this case and I was not administering the Green's WMT. Just an anecdotal observation on my part.
 
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I should be more clear. I am not questioning the validity of malingering/ effort in general, but rather a specific test. When when every person given a TOMM passes and nearly every person given a Green's Word-Memory fails, I have to question that test. Granted, N=~25 in this case and I was not administering the Green's WMT. Just an anecdotal observation on my part.

As WisNeuro mentioned, my take is that particularly depending on the population, it's more a matter of one test's lack of sensitivity using traditional scoring criteria rather than a significant false-positive rate for the other.
 

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This kind of follows with the discussion of only allowing neuropsychologists to do assessments. Anyone can administer tests and blindly follow manualized norms. But, when you don't know the specifics about the norming population, and consider the updated research, you can, and will easily misinterpret things. Like, if you didn't know the research on the WMS-IV, you might think that everyone is normal on spatial memory due to the designs subtest, even though most people will fall at least into the low average range merely by guessing.

Our strength isn't our tests, it's our knowledge of the tests, the research behind them, and our knowledge of neuroanatomy and neuropathology.
 

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Exactly, the research does not support the manualized cutoffs of the tomm in any way.

I can definitely agree about the TOMM having poor sensitivity. I have had only one person fail the TOMM in my years of giving assessments and the score was a perfect '0' on recall in a forensic case. I am less familiar with the literature on Greens. Given the discussion a second question enters my mind; why is there not a standard protocol for assessing veterans during C&P (or is there? I have been involved with the VA since 2009). Even if the person is a trained neuropsychologist, measures vary widely depending on region and preference, IME.

As for the RBANS, I have used it only in the capacity of a quick and dirty eval for functional assessment in a rehab setting. I can't imagine there is any defense for using it other than time constraints when it comes to C&P. I'd be curious to hear the reasoning.
 

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I am less familiar with the literature on Greens. Given the discussion a second question enters my mind; why is there not a standard protocol for assessing veterans during C&P (or is there? I have been involved with the VA since 2009). Even if the person is a trained neuropsychologist, measures vary widely depending on region and preference, IME.

If you've seen one VA, you've seen one VA. Also, it's highly politicized. Just look at SSA evals and how little they will allow in terms of objective testing. I would love if there were a structured battery that properly assessed the needed domains and PVT/SVT using the most up to date and rigorous literature. Just hard to get that standardized across so many sites and practitioners.
 
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It's important to note that multiple SVTs/PVTs should be utilized (both embedded and stand alone). I know people complain about the time crunch, but garbage in/garbage out if the data isn't valid.
 

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There is a qualitative difference between being dazed for a little while and being out cold for up to half an hour. However, after a few weeks, there is no quantitative difference. It's still mild and the vast vast vast majority are expected to fully recover. Same thing goes for mild TBI's separated in time given adequate recovery periods. And yes, cutoffs are blunt, which is why neuropsychologists rely on the complete picture of interview, chart review, and objective findings.
 

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As defined by performance on blunt instruments. Keep in mind in neurosurgery, it was/is kind of okay to cut a bit more out of the right hemisphere than they would out of the left. Why? Right hemisphere doesn't complain and, on conventional measures, we can't tell. Interesting how those with right hemisphere stroke have a harder time taking care of themselves. . . hmm. . .

Also as defined by return to neurochemical equilibrium. McCrae has published fairly extensively on this.

And, yeah, I would definitely rather lose right hemisphere functions. Many of the stroke and brain injury patients I've seen with extensive right hemipshere damage can actually live independently. I can't say the same for the left MCA stroke, left extensive brain damaged patients.
 

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I've seen him talk and read his articles. Neurochemical equilibrium. . . what does that mean?
.
This is not an anomalous concept. It's well studied in both the animal and human brain injury studies.

After a concussion, there is a change in the neurochemical makeup, the brain's natural response to injury. Generally excitatory neurotransmitter release, shift in ionic balance, changes in glucose metabolism. Every part of the body reacts to any kind of injury, great and small, this is how the brain reacts. This all returns to normal in these injuries within weeks.

As for the "research" on white matter injury. DTI is not ready for prime time. It runs the same problems that fMRI had in its early days. Too many people doing it with poor stats work. Yeah, if you run thousands of voxel wide comparisons without corrections for multiple comparisons, you're going to find lots of interesting things! Especially when you don't include control groups and have n's of <10. I agree that it needs more study, but there's no reason someone with a concussion/mTBI should be scoring lower than a demented individual who receives 24 hour supervised care. The kinds of things certain imaging researchers are arguing for because they would hate to finally have to use PVT testing in their studies, invalidating many of their previous studies, risking grant money. :)
 

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However, that's not really where the controversy is. There are grey issues that are hard to sort out with respect to etiology where someone might be scoring in the "normal" range on conventional neuropsych testing but still have issues compared to themselves or in domains that are harder to measure (emotional reg, impulse problems, etc. . .) where we have ecological validity limitations.

I don't think this is as much of a controversy. Although I do think a bulk of the research is confounded terribly. A lot of the mTBI research is relying on vets, and that water is extremely muddy with trauma and adjustment issues on top of a secondary gain system. I'm not saying those things you listed don't exist at all in the mTBI population, just that there are other explanations for it in many people.
 

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Yes, they are interesting because of the trauma aspects. But, when you look at mTBI populations outside of a trauma and secondary gain context, they look vastly different in terms of outcomes. They don't have symptoms that last much longer than they are supposed to. It's pretty strong evidence that there are psychosocial factors at play rather than some weird unremitting symptom resulting from a concussion.
 
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I have really been enjoying this back and forth. I love neuroscience so I figured I would throw in my two cents. It was my understanding that the nature of the injury plays a role as well. For example, many sports injuries involve rotational or coup/contrecoup forces that can lead to shearing of neuronal tracts and connections between parts of the brain. With the connection between the limbic system and frontal cortex being one particularly problematic area. Also, this shearing of these tracts can lead to an overall slowing of responses as less direct pathways are utilized. In my neuropsych classes we focused more on the sports injuries so I am not sure of the effects of being "blowed up" which is what I am led by the media to believe many of these current TBIs from vets are caused by. Just wondering what your guys thoughts are on that.
 

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"The problem with that logic is that those who do not have problems do not have problems thus they have no need to seek any sort of assistance. I don't think it would necessarily be a weird unremitting symptom. For example, kids with concussion are more likely to be diagnosed with ADHD later. Of course, it could be that kids with executive/attention issues are more likely to have a concussion. That's why the comparative data are compelling."

This isn't just retroactive review of people seeking medical services, it's the same in larger studies of those both seeking extra medical help and those who didn't. They have also done studies of outcomes depending on what kind of feedback was given. Those that were told symptoms were short lasting and would be gone within a week or two, did exactly that. Those that were briefed about all of those PCS symptoms, guess what happens to them? They don't do as well. The data at this point in time appear to overwhelmingly favor nearly full recover in a short period of time, and that those who don't are more likely suffering from psychosocial factors rather than underlying cortical or subcortical issues.
 
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...I also don't think mild TBI as a category = no long term injury. Psychosocial.premorbid factors reflect brain. Injury in patients with vulnerability may be different than injury in patients with more reserve. Yes, a week or two, you see full recovery as measured by neuropsychological tests and yes, most people will be just fine after said injury, that does not change the fact that an injury occurred and that chronic brain changes have been demonstrated to be possible after said injury.
This is the part that I'm not sold on. I am familiar with some of the research for moderate and severe TBI, but I haven't seen near the support for concussions; particularly those with no +LOC.
 

WisNeuro

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This is the part that I'm not sold on. I am familiar with some of the research for moderate and severe TBI, but I haven't seen near the support for concussions; particularly those with no +LOC.

Agreed, and there are many inherent problems with the translational research on this. I'm willing to change my thoughts on this with adequate empirical support, but I just haven't seen it yet.
 

PsyDr

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I think this is where the difference between imaging and neuropsych become apparent. There is a difference between behavioral impairment and tissue lesions. Rao has demonstrated that amlyloid plaques start in the 4th decade. Bigler has presented some evidence that the age of injury is more important to cognitive changes than the specific lesion.
 

WisNeuro

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I agree that the DTI stuff is interesting, but not close to use in primetime clinical settings yet, as much as Bigler wishes it was. Also, there needs to be better work trying to look at objective clinical findings with DTI.

As for lesions in dementia and alzheimer's, lesion load poorly predicts clinical outcomes relatively speaking. There are a few recent studies that show neuropsych performance predicts clinical outcomes better than imaging findings over time.
 

WisNeuro

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Ugh, KARE11. That "News" station absolutely hates the VA. When I lived in Minne, they frequently had news reports bashing the VA with glaring inaccuracies. Not surprised they decided to pick up a news story from another state. While I agree that the RBANS was mis-used in this case, there are a lot of things that you do not see in this news reporting. I know people involved with this case indirectly. As with most of the media accounts of the VA, there is definitely another side to this saga.
 

Pragma

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A 14 month old informed discussion of mTBI. Nice thread resurrection!

Why didn't anyone discuss qEEG?
 
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