Saint Brigid/ImPACT Concussion Seminar

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Slides from Aug 24, 2012 concussion seminar at Saint Brigid of Kildare school, presented by Dr. Mickey Collins and Dr. Jonathan French. …

Slides from Aug 24, 2012 concussion seminar at Saint Brigid of Kildare school, presented by Dr. Mickey Collins and Dr. Jonathan French.

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  • 1. Evidence-Based Management ofSports Concussion: What AreWe Learning? University of Pittsburgh Medical Center UPMC Department of Orthopaedic Surgery UPMC Sports Medicine Concussion Program
  • 2. Disclosure Statement Micky Collins, PhD is Vice President, Chief Clinical Officer, and Co- Founder of ImPACT Applications, a computerized neurocognitive test battery designed to assess sports concussion and Mild Traumatic Brain Injury.Copyright © 2011
  • 3. ObjectivesDiscuss pathophysiology of sports-relatedconcussion/mTBI.Present data pertaining to neurocognitiveoutcomes from sports concussion and riskfactors/profiles that predict protracted recovery.Discuss appropriate in-office clinical evaluationfor sports concussion/mTBI management.Present a case study of sports concussionmanagement Copyright © 2011
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  • 8. Neurometabolic Cascade Following Cerebral Concussion/MTBI 500 (Giza & Hovda, 2001) Calcium 400 % of normal 300 K+ 200 Glucose Glutamate 100 50 2 6 12 20 30 6 24 3 6 10 0 hours days minutes Cerebral Blood Flow UCLA Brain Injury Research CenterCopyright © 2011
  • 9. Concussion Management: Areas of Focus Rule out more serious intracranial pathology • CT, MRI, neurologic examination primary diagnostic tests Prevent against Second Impact Syndrome Prevent against cumulative effects of injury • Less biomechanical force causing extension of injury Prevent presence of Post-Concussion SyndromeCopyright © 2011
  • 10. Most Commonly Reported Symptoms – 1-7 days following concussion SYMPTOM PERCENT #1 Headache 75% #2 Difficulty Concentrating 57 % #3 Fatigue 52 % #4 Drowsiness 51 % #5 Dizziness 49 % #6 Foggy 47 % #7 Feeling Slowed Down 46 % #8 Light Sensitivity 45 % #9 Balance Problems 39 % # 10 Difficulty with Memory 38 % Kontos, Elbin, French Collins, Data Under Review; N = 1,438Copyright © 2011
  • 11. Post-Concussion • More emotional Symptom • • Sadness Nervousness Groups • Irritability • Headaches • Attention Problems • Visual Problems • Memory dysfunction • Dizziness • “Fogginess” • Noise/Light Sensitivity • Fatigue • Nausea • Cognitive slowing • Difficulty falling asleep N=327, High School and University • Sleeping less than usual Athletes Within 7 Days of Concussion (Pardini, Lovell, Collins, et al. 2004)Copyright © 2011
  • 12. The Evolving Definition of Concussion CDC Physicians Toolkit 2007 A concussion (or mild traumatic brain injury) is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural brain injury, and is typically associated with normal structural imaging findings (CT Scan, MRI). Concussion may or may not involve a loss of consciousness. Concussion results in a constellation of physical, cognitive, emotional, and sleep -related symptoms. Recovery is a sequential process and symptoms may last from several minutes to days, weeks, months, or even longer in some cases.”Copyright © 2011
  • 13. Management of MTBI: Topics of Concern Grading systems ineffective/not evidenced based. CT and MRI insensitive to neurometabolic effects of injury. Variability in management recommendations. Inadequate/Improper recommendations from ED/Trauma Departments/clinician offices. “Rest” does not cure all concussions. Lack of education and awareness of injury. Self-report predicating management directives.Copyright © 2011
  • 14. 26Copyright © 2011
  • 15. Return to Play Following mTBI: In some cases (not all), athletes will minimize difficulties Athletes are naïve to the subtleties of the injury Young athletes lack insight into self-assessment of MTBI symptoms Relying on subjective status of a patient with brain injury Studies suggest that up to 50% of athletes experience concussion symptoms per year but only 10 % report having an injury Need for comprehensive understanding of athletes recovery statusCopyright © 2011
  • 16. Computer-Based Neurocognitive Testing Cogsport (Axon) Headminders (CRI) ANAM CNS Vital Signs ImPACTCopyright © 2011
  • 17. ImPACTImmediate Post-ConcussionAssessment and Cognitive TestingComputerized Neurocognitive TestingMark Lovell, PhD - UPMC Dept. of Orthopaedic SurgeryMicky Collins, PhD - UPMC Dept. of Orthopaedic SurgeryJoseph Maroon, MD - UPMC Dept. of Neurological Surgery Copyright © 2011
  • 18. ImPACT: Post-Concussion Evaluation 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 On-line and In-Person training workshops available to learn interpretation Over 100 peer-reviewed research articles/books/chapters, published since 2000  Extensive data published on reliability, validity, sensitivity/specificity, added value, prognostic ability of testCopyright © 2011
  • 19. Computer-Based Neurocognitive Testing Reaction Time Processing Speed Visual Memory Verbal Memory
  • 20. Pre-season 1-3 Days First Follow-up Baseline Testing Follow- Testing Concussion Up as needed Supervised Remove Evaluation Return to Play at School From Play Or clinicCopyright © 2011
  • 21. Show Baseline VideoCopyright © 2011
  • 22. ImPACT Testing: What it is and Isn’t IS a tool to help determine recovery from injury. IS a tool to help manage concussion (e.g. return to academics, return to exertion, return to play). IS a tool to help communicate post-concussion status to coaches, parents, clinicians. IS NOT a substitute for clinical evaluationCopyright © 2011
  • 23. Sensitivity and Specificity of Computerized Neurocognitive Testing Schatz P, Pardini J, Lovell MR, Collins MW. Sensitivity and specificity of the ImPACT test battery in athletes’ concussion status. Archives of Clinical Neuropsychology 2005:21;91-99. N = 138 controls/ concussed athletes 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)Copyright © 2011
  • 24. Comparison of Preseason, Midseason and Post-Season Neurocognitive Scores in Uninjured Collegiate Football Players Miller, Adamson, Pink, Sweet, AJSM, 2007 Compared ImPACT results for 78 non-concussed, collegiate football players at preseason, midseason and post season. All athletes engaged in contact practices/games Found no statistical differences in test performance across the three evaluations “ImPACT test scores are not significantly altered by a season of repetitive contact in uninjured collegiate football athletes” “Impairment of ImPACT scores in concert with clinical symptoms/findings should be interpreted as evidence of a post-concussive event”Copyright © 2011
  • 25. Unique Contributions of Neurocognitive Assessment to Concussion Management Symptomatic Asymptomatic Control 100 Testing reveals 95 cognitive deficits 90 85 in asymptomatic 80 athletes within 4 75 70 days post-concussion 65 60 55 N=215, MANOVA 50 p<.000000 Verbal Visual Memory MemoryCopyright © 2011
  • 26. Concussion Management Programs ImPACT Computerized Neurocognitive Testing NFL (All Teams Mandated) NHL (All Teams Mandated) MLB (All Major/Minor League Teams/Umpires Mandated) Major League Soccer (all teams) US Ski/Snowboarding Teams NASCAR, IRL, CHAMP Racing Leagues USA Rugby/US Lacrosse USA Soccer Cirque de Soleil Irish National Rugby New Zealand Rugby Football Union South African Rugby European Professional Soccer World Wrestling Federation US Military (All four branches/National Guard) Over 900 Colleges/Universities Over 6,000 high schools Over 800 Primary Care and Pediatric ClinicsCopyright © 2011
  • 27. Measuring NeurocognitiveRecovery from Sports mTBI How Long Does it Take?
  • 28. Authors Sample Population Tests Utilized Total Days Cognitive Total Days Symptom Size Resolution Resolution Lovell et al. 95 Pro (NFL) Paper and Pencil NP 1 day 1 day 2005 McCrea et al. 94 College SAC 1 Day 7 days 2003 McCrea et al. 94 College Paper and 5-7 days 7 days 2003 Pencil NP Echemendia 29 College Paper and Pencil NP 3 days 3 days 2001 Guskiewicz et al. 94 College Balance 3-5 Days 7 Days 2003 BESS Bleiberg et al. 64 College Computer 3-7 days Did Not 2005 NP (ANAM) Evaluate Iverson et al. 30 High School Computer 10 days 7 Days 2006 NP (ImPACT) McClincy et al. 104 High School Computer 14 days 7-10 Days 2006 NP (ImPACT) Lovell, Collins et al 208 High School Computer 26 days 17 Days 2008 NP (ImPACT) Covassin et al 72 High School Computer 21 days 7 Days 2011 NP (ImPACT) Maugans et al 12 Ages 11-15 Computer 30 days 14 Days 2011 NP (ImPACT)Copyright © 2011
  • 29. 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)Copyright © 2011
  • 30. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 100 90 80 70 80% RECOVERED 60 50 60% 40 RECOVERED N=134 High School Male Football Athletes 30 20 40% 10 RECOVERED 0 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 ConcussionsCopyright © 2011
  • 31. Examining Relevance of “Grade 1” Concussions in High School Athletes Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32:47-54,2004Copyright © 2011
  • 32. 64 high school athletes with “mild” concussion Two groups compared in terms of outcome  Athletes with <5 min of signs/symptoms  Athletes with 5-15 min of signs/symptoms No athlete in sample sustained LOC All athletes met AAN Grade 1 criteria No athlete returned to contest ImPACT evaluation obtained at baseline, day 2, day 4, and day 7 post-injuryCopyright © 2011
  • 33. ImPACT Memory Composite Scores Brief versus Prolonged On-field Mental Status Changes 5-15 min < 5 min 90 85 P<.04 P<.02 P<.004 N = 64 80 High 75 School Athletes 70 65 60 Baseline 36 Hours DAY 4 DAY 7 ImPACT Memory-Percent Correct Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004Copyright © 2011
  • 34. ImPACT Symptom Scale Scores Brief versus Prolonged On-field Mental Status Changes 5-15 min < 5 min 40 P<.003 35 P<.061 30 N = 64 25High School NS 20 Athletes NS 15 10 5 0 Baseline 36 hours DAY 4 DAY 7 Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54, 2004Copyright © 2011
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  • 36. “Bell-Ringer” Summary First studies to challenge assumption that Grade 1 or mild concussion in high school athletes is associated with rapid and complete recovery  Findings contrary to most grading systems (AAN)  Recovery from concussion may not be linear process  Replication needed with college/professional athletes  Should high school athletes diagnosed with concussion be allowed to return to play in same contest? Lovell, Collins, Iverson, Field, Podell, Cantu, Fu; J Neurosurgery; 98:296-301,2003 Lovell, Collins, Iverson, Johnston, Bradley; Amer J Sports Med; 32;47-54,2004Copyright © 2011
  • 37. Prognosticating ProtractedConcussion Outcomes:An Evidence-Based Analysis
  • 38. Helps to set up clear communication to player, coaches, and medical personnel regarding recovery expectations May help to alleviate some pressure on RTP issue May help to immediately provide individualized clinical management recommendations (e.g. need for academic accommodations/physical rest, etc) Begins to create a risk profile for sports concussion and may set stage to effectively research treatment and rehabilitation strategies.Copyright © 2011
  • 39. Which 0n-FieldSymptoms Predict Protracted Recovery?Lau B, Kontos A, Lovell MR, Collins MW. AJSM.Vol. 39(11):2311-18; 2011 Copyright © 2011
  • 40. Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in High School Football Players? 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)Copyright © 2011 Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011
  • 41. Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players **p<.01 On-Field Marker N Chi2 P Odds 95% Confidence Ratio Interval Posttraumatic Amnesia 92 1.29 0.257 1.721 0.67-4.42 Retrograde Amnesia 97 .120 0.729 1.179 0.46-3.00 Confusion 98 .114 0.736 1.164 0.48-2.82 LOC 95 2.73 0.100 0.284 0.06-1.37 On-Field Symptom N Chi2 P Odds 95% Confidence Ratio Interval Dizziness** 98 6.97 0.008 6.422 1.39-29.7 Headache 98 0.64 0.43 2.422 0.26-22.4 Sensitivity LT/Noise 98 1.19 0.28 1.580 0.70-3.63 Visual Problems 97 0.62 0.43 1.400 0.61-3.22 Fatigue 97 0.04 0.85 1.080 0.48-2.47 Balance Problems 98 0.28 0.59 0.800 0.35-1.83 Personality Change 8 0.86 0.35 0.630 .023-1.69 Vomiting 97 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.Copyright © 2011 Lau, Kontos, Collins, Lovell , AJSM 2011
  • 42. Which Subacute Symptoms Predict Protracted Recovery?Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3):216-21 Copyright © 2011
  • 43. 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):216-21Copyright © 2011
  • 44. 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)Copyright © 2011
  • 45. FOGGY DIFF CONC VOMIT DIZZY NAUSEA HEADACHE SLOWNESS BALANCE LIGHT SENS NOISE SENS NUMBNESS 2 1.5 1 0.5 0 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.Copyright © 2011
  • 46. “It is like going from a high definition TV world to standard TV world” “Feeling one step removed from my surroundings” “It is like my vision is impaired, but it isn’t” “Feeling like I am underwater”Copyright © 2011
  • 47. Determination of Neurocognitive Cutoff Scores that Predict Protracted Recovery (at 2 days post injury) Lau B, Collins MW, Lovell MRNeurosurgery 2012;Feb 70(2):371-79. Copyright © 2011
  • 48. 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 ImPACT 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.Copyright © 2011
  • 49. Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery 75% 80% 85% Sensitivitity Sensitivity 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 Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (Mean Recovery Time = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery 2012.Copyright © 2011
  • 50. Iverson G. CJSM; 2008 Predicting Quick versus Protracted Recovery from Sports mTBI 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.Copyright © 2011
  • 51. Use of Computerized Neurocognitive Testing In High School Athletes (Meehan et al, Pediatrics 2011) 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)  93% use ImPACT 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)Copyright © 2011
  • 52. Established (?) Constitutional Risk Factors For More Complicated Recovery Age - Field, Lovell, Collins et al. J of Pediatrics, 2003 - Pellman, Lovell et al. Neurosurgery, 2006 - Mihalik, Collins,Lovell et al, J Neurosurgery, 2006 Migraine History & Symptoms Learning Disability - Collins, Lovell et al, JAMA, 1999 - Kontos, Elbin, Collins, Data submitted for publication Repetitive - Collins, Lovell et al, Neurosurgery, 2004 - Iverson et al, CJSM, 2004 Concussion? - Moser et al, JCEN, 2011 - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, 2009 Gender? - Covassin et al, CJSM, 2009Copyright © 2011
  • 53. 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 Clinical management key to preventing poor outcomes The “mild” injuries may become severe and the “severe” injuries may become mildCopyright © 2011
  • 54. Scientific Evolution and BuildingConsensus: Where are we Headed? Copyright © 2011
  • 55. Recommended Sports Concussion Management Post-Injury Management Removal from contest if concussion suspected-no RTP in same game No return to play while symptomatic or if symptomatic with exertion Carefully monitored and graded increase in exertion over time Need to be mindful of cognitive exertion on role of recovery Need for conservative management in children/adolescents Neurocognitive testing recommended for athletes sustaining concussion Criteria for Return to Play 1. Symptom-Free at Rest 2. Symptom-Free with Cognitive/Physical Exertion 3. Normal Neurocognitive Data/Objective EvaluationCopyright © 2011
  • 56. - Education necessary- Dept of Education will post concussion educational information; Student/parents must sign form prior to participation that they have reviewed concussion fact sheet. Coaches must complete concussion management training course on yearly basis. Informational school meetings are encouraged that educate on concussion management and importance of baseline assessments that can aid in evaluation and management of injury. - Any athlete exhibiting signs/symptoms of concussion shall be removed from practice/game and no RTP on day of injury. Medical clearance must occur from: Physician trained in concussion management OR licensed physician designee trained in concussion management, OR licensed neuropsychologist (fellowship trained) who has specific training in concussion management. Penalties occur with any infraction.Copyright © 2011
  • 57. Clinical Implementation: Concussion Management
  • 58. The UPMC Sports Concussion Program ATC from Pediatric Contracted Practices Schools Emergency Primary Care Departments Physicians UPMC Concussion Program (Neuropsych)Parents Vestibular //Schools / Parents Neuro Orthopaedic Behavioral PM & R Physical School Radiology /Neuro Neuro- Therapy Surgery Optometry
  • 59. UPMC Typical Evaluation Detailed Clinical Interview Vestibular Screening 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.
  • 60. Clinical Evaluation  Clinical Interview  Vestibular & Ocular Screening  Computerized Neurocognitive TestingCopyright © 2011
  • 61. Factor Analysis, Post-Concussion • More emotional Symptom Scale • Sadness • Nervousness (Pardini, Lovell, Collins • Irritability et al. 2004) • Headaches • Attention Problems • Visual Problems • Memory dysfunction • Dizziness • “Fogginess” • Noise/Light Sensitivity • Fatigue • Nausea • Cognitive slowing N=327, High School • Difficulty falling asleep and University • Sleeping less than usual Athletes Within 7 Days of ConcussionCopyright © 2011
  • 62. Symptom Evaluation/Clinical Interview: What is Asymptomatic? IS NOT “How are you feeling?” or “Do You Have a Headache?” IS a series of questions inquiring about subtleties of injury “Do you have a pressure in your head that increases as day progresses?” “Do you feel more fatigued than normal at the end of the day?” “Do busy environments cause you to feel foggy, anxious, tired?” “Do you become dizzy when looking up/down, turning head, standing quickly?” “Do you have blurred or fuzzy vision while reading or difficulty reading?” “ Do you feel a frontal pressure in your head when reading/computer work?” “Do you feel more distractible in school than normal?” “Are you having more significant difficulty in Math and Science?” “Do you have difficulty falling/staying asleep?” “Have you or your parents noticed that you are more irritable than normal?”Copyright © 2011
  • 63. Acute Concussion Evaluation Gioia, Collins 2006 CDC Toolkit for PhysiciansCopyright © 2011
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  • 65. Copyright © 2011
  • 66. Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery 75% 80% 85% Sensitivitity Sensitivity 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 Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (Mean Recovery Time = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery 2012.Copyright © 2011
  • 67. ImPACT Domain Mean RCI 90% Confidence Interval ImPACT Verbal Memory Score Time 1 88.6 8.75 Time 2 88.8 ImPACT Visual Memory Score Time 1 78.7 13.5 Time 2 77.5 ImPACT Processing Speed Score Reliable change methodology Time 1 40.54 4.98 is designed to identify cutoffs Time 2 42.24 that can be used for meaningful comparisons of ImPACT Reaction Time Score test scores that are Time 1 .543 .06 independent of practice effects and other sources of Time 2 .536 variance ImPACT Symptom Score Time 1 5.23 9.6 Iverson et al, TCN 2005 Time 2 5.79Copyright © 2011
  • 68. Clinical Evaluation  Clinical Interview  Vestibular-Ocular Screening  Computerized Neurocognitive TestingCopyright © 2011
  • 69. Vestibular-Ocular Screening • 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 closedCopyright © 2011
  • 70. Vestibular-Ocular Screening Expected Symptoms/Environmental Triggers Domain Symptoms Main Environmental Quote from Patients Triggers Saccadic Eye Movements- Headache, Fatigue, Computer Work, “Its like my eyes are Vertical and Horizontal Difficulty Reading, Watching playing a slow game of concentrating Action Movies, Video ping pong” Games Gaze Stability-Vertical and Fogginess, Headache, Note Taking, Busy “It feels like I am outside Horizontal Fatigue, Dizzy, Anxiety Environments, Hallways, myself, one –step behind, Running, Gymnasiums, and the world is in slow Busy Weightrooms motion” Ocular Convergence Headache (frontal), Reading, Computer Work, “I feel like two fat men (Convergence Insufficiency) Fatigue, Irritability Texting, Math and with two fat asses are Chemistry, sitting on my eyes” VOR Cancellation Nausea, Headache, Car Rides, “While at the mall, I feel Fogginess, Fatigue, Supermarkets, Busy like I am looking out the Depersonalization, Environments, Wide side window of a high- Anxiety Open Spaces speed car…I just want to get out of there and it freaks me out”Copyright © 2011
  • 71. Copyright © 2011
  • 72. 15 year old, Sophomore Honors student, High Average standardized testing No other medical history-no prior concussion Strong migraine history in maternal family In retrospect, difficulties with concussion started on September 11, 2009Copyright © 2011
  • 73. Initial injury in video caused bilateral blurred vision, dizziness, photo/phonphobia, nausea, difficulty with play calls No LOC, amnesia or mental status change Never reported hit or symptoms to ATC, though told teammates Second event in video worsened symptoms That evening, told parents of symptoms (minimized difficulties) No other medical intervention Played remainder of season Symptoms ebbed/flowed depending upon exertion and contact to head Grades dropped during course of season (Straight A’s to C range) Symptoms persistent throughout entire season Sustained “another” concussion 10/30/09 (2nd to last game)-posterior blow • Reported to ATC week after game/Referred to UPMCCopyright © 2011
  • 74. November 16, 2009 Evaluation (2 Months after initial event) Headaches daily in school (7/10-generalized pressure), moderate fatigue, “feeling slow”, fogginess, general dizziness, distractible, short term memory difficulty Discussed inherent pressure of playing quarterback, team culture of playing through injury, pressure from coaches/family/friends “Knew it was concussion, but nothing serious” “Would be fine in long run” “Good time to report injury given break from conditioning-no football responsibilities” Father nonchalant, mother very concerned-discussed team/community culture of football Physical evaluation indicated convergence insufficiency, provocative dizziness with horizontal/vertical saccades and gaze stability, balance WNL ImPACT TestingCopyright © 2011
  • 75. Vestibular-Ocular Screening • 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 closedCopyright © 2011
  • 76. Copyright © 2011
  • 77. Cutoff Values of ImPACT Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery 75% 80% 85% Sensitivitity Sensitivity 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 Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (Mean Recovery Time = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery 2012.Copyright © 2011
  • 78. Recommended formal Vestibular Evaluation (UPMC- Eye and Ear Institute/Center for Rehabilitation Services) Patient strongly desired to remain in school Allowed ½ days for 2 weeks Provided full academic accommodations-including no tests for 3 weeks, ½ work assignments, books on tape if possible, extensions on all assignments, leaving class early, avoiding high stimulus areas, excused absences from school- recommended meeting with all teachers Return evaluation in 2 weeks to monitor statusCopyright © 2011
  • 79. November 30 Evaluation Vestibular Therapy initiated Home-Based program outlined, Patient compliant Symptoms not improved and persistent Patient vocalized concerns over injury, response from coaching staff, etc. “Play through pain culture” Both parents understanding and concerned Teachers helpful at providing accommodations Father trying to “educate” others regarding injury Vestibular screening improved, but remained abnormal ImPACT TestingCopyright © 2011
  • 80. Copyright © 2011
  • 81. Continued Vestibular Therapy-no exertion until WNL Recommended homebound instruction Recommended medication referral Dr. Camiolo-Medical Advisor-UPMC Sports Concussion Program Amantadine 200mg Follow up in 2-3 weeksCopyright © 2011
  • 82. Factor Analysis, Post-Concussion • More emotional Symptom Scale • Sadness • Nervousness (Pardini, Lovell, Collins • Irritability et al. 2004) • Headaches • Attention Problems • Visual Problems • Memory dysfunction • Dizziness • “Fogginess” • Noise/Light Sensitivity • Fatigue • Nausea • Cognitive slowing N=327, High School • Difficulty falling asleep and University • Sleeping less than usual Athletes Within 7 Days of ConcussionCopyright © 2011
  • 83. Emotionality SSRIs Escitalopram (Lexapro) Somatic Sertraline (Zoloft) Symptoms Therapy Headaches Prophylaxis Cognitive Symptoms  Propranolol* Neurostimulants  Verapamil* Amantadine*  Amitriptyline* Methylphenidate*  Escitalopram (Lexapro) Sleep Atomoxetine (Strattera)*  Sertraline (Zoloft) Disturbance Vestibular Therapy Melatonin Trazodone NOTE: *Off-label useCopyright © 2011
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  • 85. December 18, 2009 (3 months post-injury) Headaches 1/7 days (1/10, 20 minute duration), mild perceived difficulty with short-term memory No other symptoms reported Discharged from Vestibular therapy-all WNL Started Exertional Physical Therapy Sean Learish,PT-Center for Rehab Services-Director of Exertional PT- UPMC Sports Concussion Program ImPACT TestingCopyright © 2011
  • 86. 5 Stage Post-Concussion Exertion Program Target Exertion calculated by Karvonen’s equation: [ {Max. H.R. (220-Age) – Resting H.R.} X Target % ] + Resting H.R.Stage ActivityStage 1 - Very light aerobic conditioningTarget Heart Rate : 30-40% of maximum exertion - Sub-max strengtheningRecommendations: 10-15 minutes of cardio exercise; lowstimulus environment; no impact activities; balance and - ROM/ Stretchingvestibular treatment (prn); limit head movement/ position - Very low level balance activitieschange; limit concentration activitiesStage 2 - Moderate aerobic conditioning - Light weight strength exerciseTarget Heart Rate : 40-60% of maximum exertion - Stretching (active stretching initiated)Recommendations: 20-30 minutes of cardio exercise;exercise in gym areas; use various exercise equipment; - Low level balance activitiesallow some positional changes and head movement; low levelconcentration activitiesStage 3 - Moderately aggressive aerobic exercise - All forms of strength exercise (80% max)Target Heart Rate: 60-80% of maximum exertion - Active stretching exerciseRecommendations: any environment ok for exercise (indoor,outdoor); integrate strength, conditioning, and balance / - Impact activities running, plyometrics (noproprioceptive exercise; incorporate concentration challenges contact)Copyright © 2011 - Challenging proprio-balance activities
  • 87. 5 Stage Post-Concussion Exertion Program Target Exertion calculated by Karvonen’s equation: [ {Max. H.R. (220-Age) – Resting H.R.} X Target % ] + Resting H.R. Stage Activity Stage 4 (Sports Performance Training) - Non-contact physical training Target Heart Rate: 80-90% of maximum exertion - Aggressive strength exercise Recommendations: continue to avoid contact activity, - Impact activities/ plyometrics resume aggressive training in all environments - Sports specific training activities Stage 5 (Sports Performance Training) - Resume full physical training activities with contact Target Heart Rate: Full exertion - Continue aggressive strength/ Recommendations: Initiate contact activities as conditioning exercise appropriate to sport activity; full exertion for sport - Sport specific activitiesCopyright © 2011
  • 88. Show JB VideoCopyright © 2011
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  • 90. December 18 recommendations Return to full school, minimal accommodations (breaks from class if needed, tutoring in difficult classes, extensions all assignments) Progress with exertional therapy to Stage 3-4 No contact sports Continue Amantadine Follow up 1 monthCopyright © 2011
  • 91. January 11, 2010 (4 months post-injury) Off Amantadine Reported circumscribed short term memory difficulties Doing well in school-full curriculum No other symptoms reported Stage 4 Physical Exertion-no difficulties Vestibular screening WNL ImPACT TestingCopyright © 2011
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  • 93. January 11, 2010 Recommendations Continue Exertion as tolerated Follow up in February for monitoring of statusCopyright © 2011
  • 94. February 22, 2010 Evaluation 100% asymptomatic-no difficulties reported Full physical and cognitive exertion Grades returned completely to normalCopyright © 2011
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  • 96. February 22, 2010 Recommendations Full clearance back to all sports, including football Quotes from Family: Both “Felt educated about injury” Strong desire to “educate others” Reported misperceptions of others Concussion is always repetitive and cumulative Son has “permanent damage” Son would “never” return to football Son would “never be the same cognitively or physically” Son should “never play football again” (from same people who questioned veracity of injury to begin with) “Poor education throughout community-from coaches to clinicians”Copyright © 2011
  • 97. Thank You Micky Collins, Ph.D. collinsmw@upmc.edu 412-432-3668 (Direct) or 412-432-3681 (Secretary)Copyright © 2011