Return-to-Play Decision-Making From a Neuro-Vision Perspective. David H. Biberdorf, OD, FCOVD

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1 Return-to-Play Decision-Making From a Neuro-Vision Perspective David H. Biberdorf, OD, FCOVD

2 Post-Concussion Vision Problems 90% of all concussions will have 1 or more ocular problems Symptoms may include light sensitivity, headaches, eyestrain, blurred vision, double vision, motion sensitivity, disequilibrium, reading problems Hidden vision problems frequently persist 6-9 months after a concussion

3 When is the Visual System Ready to Play? Visual Software Visual Hardware

4 What is the rationale for a targeting the visual system for concussion rehabilitation? If not addressed, post-concussion vision problems may create a bottleneck on information processing and delay recovery. Limited attention/energy will be consumed by an inefficient system or diverted elsewhere. This will cause peripheral narrowing, which puts an athlete at risk. Vision rehabilitation results in a faster recovery and helps to avoid secondary issues like: sedentary state; depression; sleep disorder; social isolation; and exponential loss of function.

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6 CDC RTP Guidelines Baseline Resting athletes should not have any concussion symptoms Day 1 Light aerobic exercise (walk, stationary bike, no resistance) Day 2 Moderate sport specific activity (running/resistance training) Day 3 Add non-contact activities (Skill Drills) Day 4 Return to full contact practice Day 5 Athlete returns to competition Each step 24 hours; if post-concussion symptoms occur during program, student-athlete should drop down to previous asymptomatic level and try again after further 24 hour period of rest has passed.

7 Zurich International Consensus Statement for Consussion (2012) Graded RTP Multidisciplinary targeted treatment for difficult patients

8 NCAA RTP Best Practice Guidelines for Concussion (2014) Active, targeted treatments of oculomotor system are encouraged Vision therapies that target deficits such as accommodative and convergence insufficiencies, impaired version eye movements and ocular misalignments may be effective for treating athletes with vision and ocular motor clinical profiles.

9 Targeted Evaluation & Active Treatment (TEAM) Approach to Treating Concussion Concussion Meeting October 15-16, 2015 in Pittsburgh, PA Focus was on treating concussion 37 multidisciplinary participants from: neurology, neurosurgery, neuropsychology, primary care, athletic training, physical therapy, research... Recovery can last up to 4 weeks for symptoms, 3 weeks for memory and 3 weeks for oculomotor/vestibular Matching targeted and active treatments (including oculomotor therapy) to clinical profiles may improve recovery trajectories following concussion.

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11 What about visual software? Visual Software

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13 An Exploratory Study of the Potential Effects of Vision Training on Concussion Incidence in Football, Clark J, et al. Optometry & Vis Perf (2) 2015 Concussion incidence rate was 5.1 cases per 100 player seasons prior to Starting in 2011 team engaged in visual software training each year prior to season. For the following four seasons, the rate dropped to 1.4 concussions per 100 player seasons compared to players who did not receive the vision training (9.2 concussions per 100 player seasons; p<0.001.)

14 New Tools to help with RTP Decision-Making Senaptec Sensory Station: Assesses 10 important sports-specific skills for athletes and compares them with others of the same skill level & position NeuroTracker: Multiple object tracking system that simulates the decision-making complexity required in athletic completion

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16 Potavski & Biberdorf (2017) Evaluation of the effectiveness of Sports Vision programs in improving performance and health in ND youth athletes year-old youth hockey players trained 10 weeks on oculomotor and visual software visual processing skills 5 weeks of oculomotor training alone effectively improved 6 out 10 SENAPTEC measures in both concussed and non-concussed athletes Both Oculomotor and Visual Software training showed SENAPTEC improvement for concussed and non-concussed athletes Oculomotor training was somewhat more effective than Software Training for non-concussed athletes on measures of reaction time and Eye-Hand coordination

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18 The effect of visual and sensory performance on head impact biomechanics in college football players. Harpham, et al, 2014 Ann. Biom. Eng 42(1): Division I college football players from 2012 UNC Football Team Used Nike Sensory Station to assess each athlete prior to season Used Head Impact Telemetry System to collect data on linear acceleration, rotational acceleration, and severity during season Poor Perception Span, Target Capture, Go/No Go, and Depth Perception scores correlated with increased impact severity Visual and sensory performance may be related to their ability to anticipate and react to impending head impacts on the field.

19 Using the Senaptec Performance Profile as a RTP Decision-Making Tool Obtain Senaptec Profile at initial visit Train both visual hardware and visual software skills Repeat Senaptec Profile Attempt to achieve the 50 th percentile in all 10 areas before athlete RTP to avoid bottlenecks during athletic performance Watch Perception Span, Target Capture, Go/No Go, and Depth Perception especially as these were the highest predictors for severity of head injury in Harpham s UNC Football Study.

20 Case Study: OG, 21 y/o UND Soccer Player Concussion in September 2017 Diagnosed with oculomotor and non-oculomotor vision problems December 2017 along with persistent visual symptoms Had not yet been cleared to RTP After 3 months of visual hardware and software vision rehabilitation, improvement noted in 5 Senaptec areas; symptoms improving Continued training advised on multiple object tracking, peripheral awareness and depth perception (stereoscopic vision)

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23 NeuroTracker Perceptual-Cognitive Testing and Training

24 OG NeuroTracker Report: Sitting, 7 sessions

25 Visual Software Training Study: Using a dual-task NeuroTracker protocol to investigate motor and cognitive performance in healthy children and youth Canadian multi-site study assessed 106 healthy children and youth (5-18 years old), on both single-task and dual-task performance. Single-task tests involved a balance exercise with varying degrees of difficulty (motor), and NeuroTracker (cognitive). The dual-task test involved performing them both at the same time. The participants focused on maintaining their NeuroTracker levels so the researchers could discover the impact of cognitive load on motor-skill function. The main symptoms of mtbi can appear to have cleared, yet the rigorous demands of training and competing can reveal lingering effects which impair performance. In worst case scenarios, this can lead to repeat concussions, due to the athletes situational awareness and response times remaining impaired.

26 Conclusions Many visual hardware and visual software post-concussion problems can remain hidden after symptoms have cleared Using tools such as the Senaptec Sensory Station and NeuroTracker clinicians may have a better sense of how athletes visual processing will perform in actual competition prior to RTP To improve athlete safety and performance, revised RTP guidelines may want to include the training of both visual hardware and visual software skills under demanding multisensory conditions