Disclosure Statement 8/25/2014. Lecture Goals. Sports Concussion: The Diagnostic and Return to Play Dilemma

Transcription

1 Evidence-Based Clinical Management of Sports Concussion: What are we Learning? Micky Collins, PhD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program Disclosure Statement Micky Collins, PhD is a Co-Founder and Board Member of ImPACT Applications, a computerized neurocognitive test battery developed to assess sports concussion and Mild Traumatic Brain Injury. Lecture Goals Discuss the biomechanics, pathophysiology, and signs/symptoms of sports-related mtbi Discuss clinical recovery rates following sports-related mtbi and risk profiles that predict more protracted recovery Discuss the role of computerized neurocognitive testing and vestibular-ocular screening as effective tools in the assessment and management of sports-mtbi Discuss the role of a multidisciplinary treatment team and the concept of targeted clinical pathways for the rehabilitation of sports mtbi Present a case study of effective concussion management Sports Concussion: The Diagnostic and Return to Play Dilemma 1

2 Linear Injury Rotational Injury 2

3 3

4 Neurometabolic Cascade Following Cerebral Concussion/MTBI 500 (Giza & Hovda, 2001) 400 Calcium % of normal K+ Glucose Glutamate minutes hours days Cerebral Blood Flow UCLA Brain Injury Research Center 4

5 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 Syndrome 5

6 Most Commonly Reported Symptoms 1-7 days following concussion SYMPTOM # 1 Headache 75% PERCENT # 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, AJSM, 2012; N = 1,438 Symptoms may evolve over time. Delayed symptoms may occur Factor Analysis, Post-Concussion Symptom Scale N=1,438 High School & University Athletes at 1-7 Days Post- Concussion Vomiting Numbness Diff. Remembering Foggy Dizziness Sadness More Emotional Nervous Diff. Concentrating Sensitivity Light/Noise Slowed Down Drowsiness Fatigue Headache Sleep Less Trouble Falling Asleep Kontos, Elbin, Schatz, Covassin, Henry, Pardini, Collins; AJSM, 2012 The Evolving Definition of Concussion Centers for Disease Control 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. Management of Sports Concussion: Topics of Concern No imaging technique or biomarker available to diagnose injury Lack of well controlled, prospective studies on long-term outcomes Lack of targeted clinical and treatment pathways Variability in clinical management and treatment recommendations Rest does not cure all concussions Media hysteria driving public perception Self-report predicating management directives. 6

7 Return to Play Following mtbi: In some cases (not all), athletes will minimize difficulties Athletes are naïve to the subtleties of the injury (particularly youth athletes) 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 status 25 Computer-Based Neurocognitive Testing Cogsport (Axon) Headminders (CRI) ANAM CNS Vital Signs ImPACT Computerized Neurocognitive Testing: Post-Concussion Evaluation Minute, On-Line Office-Based Tool 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 (demarcates poor effort) On-Line Version Available Extensive normative data available from ages Over 175 peer-reviewed research articles published since 2000 Extensive data published on reliability, validity, sensitivity/specificity, added value, and prognostic ability of test 7

8 Concussion Evaluation Timeline- Computerized Neurocognitive Testing Pre-season 1-3 Days Does Computerized Neurocognitive Testing Work? Examining Sensitivity/Specificity of Testing Baseline testing Concussion First follow-up Follow-up testing as needed Supervised by ATC, PT Physician, Clinic, or School Sideline Evaluation -Any symptoms of mtbi precludes RTP for remainder of contest Post-Injury Office/Clinic Evaluation -Interpreted by Trained Clinician Return to play Sensitivity and Specificity of Computerized Neurocognitive Testing Schatz P, Sandel N. Sensitivity and Specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, Two Athlete Groups Examined Study 1 (Concussed symptomatic athletes) 162 athletes 81 concussed athletes (diagnosed by ATC/Physician) 81 carefully matched controls (non-concussed) matched on specific basis of gender, sport, concussion history, absence of LD/ADD Discriminate Function Analysis on subscale scores; no clinician input Testing completed within 3 days post injury Sensitivity/Specificity of neurocognitive testing determined Sensitivity and Specificity of Computerized Neurocognitive Testing Schatz P, Sandel N. Sensitivity and Specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, Study 1 (Concussed symptomatic athletes) Sensitivity (91.4%) (Probability that that a concussion is present when test is positive) Specificity (70.1%) (Probability that a concussion is not present when test is negative) 8

9 Sensitivity and Specificity of Computerized Neurocognitive Testing Schatz P, Sandel N. Sensitivity and Specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, Study 2 (Asymptomatic concussed athletes) 74 Athletes 37 athletes diagnosed with on-field concussion by ATC/physician, seen within 3 days of injury, and symptom score of 0 37 carefully matched controls (non-concussed) matched on specific basis of gender, sport, concussion history, absence of LD/ADD Discriminate Function Analysis on Subscale scores; no clinician input Testing completed within 3 days post injury Sensitivity/Specificity of Computerized Neurocognitive Testing determined Sensitivity and Specificity of Computerized Neurocognitive Testing Schatz P, Sandel N. Sensitivity and Specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, Study 2 (Asymptomatic concussed athletes) Sensitivity (94.6%) (Probability that that a concussion is present when test is positive) Specificity (97.3%) (Probability that a concussion is not present when test is negative) Does Computerized Neurocognitive Testing Work? Examining the Reliability of Testing One Year Stability of Computer NP Testing in a High School Sample (On-Line Version) Verbal Memory Visual Memory Process Speed RT Symptoms Time Time r Inter-class correlation coefficients. N=369 non concussed athletes, DF=368, Bonferonni correct alpha p<.01 Schatz, AJSM,

10 Domain Mean RCI 90% Confidence Interval Verbal Memory Score Time Time Visual Memory Score Time Time Processing Speed Score Time Time Reaction Time Score Time Time Symptom Score Time Time Test-Retest Reliable Change Index Scores for Test Battery Reliable change methodology is designed to identify cutoffs that can be used for meaningful comparisons of test scores that are independent of practice effects and other sources of variance Iverson et al, TCN 2005 Composite Score Summary of Results Summary composite scores for Verbal Memory, Visual Memory, Reaction Time, Processing Speed, and Impulse Control Authors Sample Size Population Tests Utilized Total Days Cognitive Resolution Total Days Symptom Resolution Measuring Neurocognitive Recovery from Sports mtbi Lovell et al McCrea et al McCrea et al Echemendia 2001 Guskiewicz et al Pro (NFL) Paper and Pencil NP 1 day 1 day 94 College SAC <1 Day 7 days 94 College Paper and 5-7 days 7 days Pencil NP 29 College Paper and Pencil 3 days 3 days NP 94 College Balance 3-5 Days 7 Days BESS Bleiberg et al Iverson et al McClincy et al Lovell, Collins et al 2008 Covassin et al 2011 Maugans et al College Computer NP 30 High School Computer NP 104 High School Computer NP 208 High School Computer NP 72 High School Computer NP 12 Ages Computer NP 3-7 days Did Not Evaluate 10 days 7 Days 14 days 7-10 Days 26 days 17 Days 21 days 7 Days 30 days 14 Days 10

11 Individual Recovery From High School Football- Related Concussion: How Long Does it Take? WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 40% RECOVERED 60% RECOVERED 80% RECOVERED N=134 Concussions All Athletes No Previous Concussions 1 or More Previous Concussions Collins et al., Neurosurgery 3 Year Prospective Study of 17 High School American FootballTeams N=2,141 Prognosticating Complicated Concussion Outcomes: An Evidence-Based Analysis Which On-Field Symptoms Predict Protracted Recovery (> 3 weeks of recovery time) Lau B, Kontos A, Lovell MR, Collins MW; AJSM 2011 Which On-Field Symptoms Predict Protracted Recovery Time? Methodology 176 male high school and college football players Athletes had baseline neurocognitive testing and were revaluated within three days of injury. All followed until clinical recovery Within RCI of baseline on for neurocognitive/symptom scores 32% of sample required < 7 days until recovery (N =56) Rapid Recovery (Mean=4.9 days) 17% of sample required > 21 Days until recovery (N=31) Protracted Recovery (Mean =33.2 days) 39% of sample required 7-14 days until recovery (N = 68) (Continued) 11

12 Which On-Field Symptoms Increase Risk of Post Concussion Syndrome in Football Players? (Continued) 12% lost to follow up (e.g. did not RTP or no follow-up in clinic) (N = 21) MANOVA used to determine differences between rapid/> 3 week recovery ATC s documented on-field markers (e.g. LOC, Confusion, Amnesia) and onfield Symptoms (e.g. headache, dizziness, balance, photosensitivity, etc.) Which On-Field Markers/Symptoms Predict 3 or More Week Recovery from MTBI In High School Football Players On-Field Marker N Chi 2 P Odds Ratio 95% Confidence Interval Posttraumatic Amnesia Retrograde Amnesia Confusion LOC On-Field Symptom N Chi 2 P Odds Ratio 95% Confidence Interval Dizziness** Headache Sensitivity LT/Noise Visual Problems Fatigue Balance Problems Personality Change Vomiting **p<.01 Lau B, Kontos A, Lovell MR, Collins MW, AJSM 2011 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 The N column represents the number of subjects for whom data were available for each category. Markers of injury are not mutually exclusive. Lau, Kontos, Collins, AJSM 2011 Which Symptoms at 3 Days Post Injury Best Predict Protracted Recovery? Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3): 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 Lau B, Lovell MR, Collins MW; Pardini J; CJSM 2009 (3): Visual problems (blurry or double vision) 12

13 Top 11 Symptom Predictors of Protracted Recovery Do Post-Traumatic Migraine Symptoms Predict Protracted Recovery Following Concussion? Kontos A, Elbin RJ, Collins MW et al. AJSM, Expressed as Effect Sizes (Cohen s D). Only includes symptoms with large (greater than.80) effect sizes. Sample is composed of 108 male high school football athletes. Lau, Lovell, Collins et al. 2009, CJSM Post-traumatic Migraine (PTM) Defined Post-traumatic Migraine Headache, nausea, AND sensitivity to light OR noise (International Headache Society Guidelines) Determined by utilizing PCSS at 1-7 days post-concussion Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, Collins MW; AJSM, 2013 Study Overview 174 high school athletes with a concussion No prior hx of LD, moderate TBI, psychiatric disorder Athletes followed until recovery Neurocognitive scores returned to baseline (w/in RCI) Symptom free and rest and exertion 97 athletes met Rapid or Protracted Criteria for Recovery: Rapid ( 7 days)= 61 Protracted ( 21 days)= 36 Recovery studied for three groups No headache group Headache only group Post-traumatic migraine group (headache with nausea and/or light and noise sensitivity) Data Analysis Chi-square analysis with Odds Ratios for Recovery Time Groups Repeated measures ANOVAs for computerized neurocognitive test scores across 3 time periods Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, Collins MW; AJSM,

14 How do Sub-acute Post-traumatic Migraine (PTM) symptoms compare to No Headache and Headache groups in predicting Protracted (>21 days) Recovery from Sports Concussion? (N= 97)-Kontos, Elbin, Collins et al, AJSM, In Press. Variable Wald p PTM v. No Headache Headache v. No Headache PTM Group = Headache with Nausea and/or Light or Noise Sensitivity-IHS criteria Headache Group= Headache only Odds Ratio 95% CI PTM v. Headache It s More than Just a Headache! Visual Memory Raw Score PTM = Post Traumatic Migraine N = 97 HS Athletes with concussion Comparison of Visual Memory scores for PTM, Headache, and No PTM or Headache groups (λ=.88, F= 4.24, p=.002, η 2 =.06)* *PTM significantly different than both groups at 1-7 and 8-14 days PTM defined as headache with nausea and sensitivity to light or noise (IHS Classification) Determination of Neurocognitive Cutoff Scores that Predict 3 or more weeks of recovery Lau B, Collins MW, Lovell MR Neurosurgery 2012;Feb 70(2): Cutoff Values of Neurocognitive Scores at 2 Days Post Injury That Predict Protracted Recovery 75% Sensitivity 80% Sensitivity 85% Sensitivity Neurocognitive Domain Cutoff Cutoff Cutoff Verbal Memory Visual Memory Processing Speed Reaction Time Sensitivity is defined as the ability of the cutoff to accurately identify protracted recovery (Mean = 1 month) in an athlete. Lau B, Collins MW, Lovell MR. Neurosurgery

15 Case Example: NFL Defensive Back Established (?) Constitutional Risk Factors For More Complicated Recovery Following Concussion Younger Age - Field, Lovell, Collins et al. J of Pediatrics, Pellman, Lovell et al. Neurosurgery, 2006 Migraine History & Symptoms - Mihalik, Collins, Lovell et al, J Neurosurgery, Kontos, Collins, Elbin, French, Simenski, AJSM, Learning Disability - Collins, Lovell et al, JAMA, Kontos, Elbin, Collins, Brain, 2013 Repetitive Concussion - Collins, Lovell et al, Neurosurgery, Iverson et al, CJSM, Moser et al, JCEN, 2011 Female Gender - Colvin, Lovell, Pardini, Mullin, Collins, AJSM, Covassin et al, CJSM, 2009 What We Know Outcomes are highly variable Vestibular-related symptoms (dizziness/fogginess) and migraine history/symptoms best predict protracted recoveries Effective sideline management is key-removal from play a must when symptoms occur Return to play prior to full recovery from concussion will result in worse outcome and less force causing re-injury. Neurocognitive testing is an effective tool to help quantify the injury and guide the management and RTP process. The mild injuries may become complicated and the severe injuries may become mild Proper Clinical management is best form of prevention Targeted clinical pathways for treatment and rehabilitation are being established Establishing a Clinical Model of Care for Managing Sports Concussion: Targeted Assessment, Treatment and Rehabilitation Micky Collins, PhD University of Pittsburgh Medical Center Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program 15

16 The UPMC Sports Medicine Concussion Program Department of Orthopaedic Surgery UPMC Sports Medicine Concussion Program Referral Sources Emergency Departments Pediatric Practices Certified Athletic Trainers Primary Care Physicians UPMC Sports Concussion Program: Comprehensive Assessment Approach Neurocognitive Over 20, 000 patient visits annually UPMC Concussion Program (Neuropsychology) Vestibular Physical Exertion Concussion Primary Care Sports Med PM & R Vestibular / Physical Therapy Neuro Radiology Orthopaedic /Neurosurgery Behavioral Neuro- Optometry Ocular- Motor Symptoms Further Assessment and Treatment-If Indicated 16

17 Concussion Clinical Trajectories: A New Model for Understanding Assessment, Treatment and Rehabilitation? Vestibular Using Concussion Clinical Trajectories to Inform Targeted Treatment Pathways Pre-Existing Risk Factors Extensive Data Published on Risk Factors Concussion Concussion Clinical Trajectories Treatment and Rehab Pathways Anxiety/ Mood Concussion Ocular Previous Concussions Migraine LD/ADHD Ocular Vestibular Cognitive Cervical Post- Traumatic Migraine Cognitive/ Fatigue Female Gender Age Motion sensitivity, Ocular Dysfunction Migraine Cervical Anxiety/ Mood UPMC Clinical Evaluation Detailed Clinical Interview Computerized Neurocognitive Testing Vestibular-Ocular Screening Patient feedback Severity of Injury Subtype-Trajectory of Injury? Prognosis for Recovery? Need for Further Assessment/Treatment? Vestibular Therapy? Vision Therapy? Medication Management? Type/Level of Physical Exertion Allowed? Academic Accommodations? Return to Play? In-Office Evaluation Clinical Interview Computerized Neurocognitive Testing Vestibular-Ocular Screening 17

18 Why Assess the Vestibular-Ocular Systems? Subjective Complaints of Dysfunction Dizziness, Fogginess, Feeling detached, Fatigue Motion discomfort, Nausea Intolerance to busy places Anxiety/Irritability Difficulty focusing, Blurred vision, Difficulty with Math/Reading Impaired balance UPMC Vestibular/Ocular Motor Screening Form (VOMS) Symptoms Reported By Patient on 0-10 Point Scale UPMC Vestibular/Ocular Motor Screening Form (VOMS) cm 10 cm 12 cm Symptoms Reported By Patient on 0-10 Point Scale 18

19 Purpose Vestibular-Ocular Motor Screening (VOMS) Assessment Preliminary Findings for the Validity, Reliability, and Relationship of the VOMS to Established Measures 1. Describe the VOMS and provide initial support for the validity and reliability of the measure. 2. Examine the relationship of the VOMS to established measures (e.g., computerized neurocogntive testing, symptoms, and clinical balance measures). Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). Overview Participants: 85 consecutive patients (M = 14.07, +/ yrs) seen at 5.66 days (SD = 5.18) following a diagnosed sport-related concussion. 85 controls (M= ± 1.80 yrs) randomly selected from 112 consecutive athletes who participated in a concussion education and outreach testing program. Procedures: Trained clinicians administered the following assessments: Vestibular/Ocular Motor Screening (VOMS), Post-concussion Symptom Scale (PCSS), Immediate Post-concussion Assessment and Cognitive Test (ImPACT), and Balance Error Scoring System (BESS)- concussed only Vestibular-Ocular Motor Screening (VOMS) Assessment Is the VOMS reliable? Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). 19

20 The VOMS is Reliable The internal consistency of the VOMS total symptom scores and the NPC distance was high: Cronbach s alpha = 0.91 All of the items contributed positively to the overall reliability of the VOMS Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). Vestibular-Ocular Motor Screening (VOMS) Assessment Is the VOMS Sensitive? What is the Diagnostic Accuracy of the VOMS? Nearly 60% of patients report at least one provoked symptom following the VOMS (N = 85). Concussed patients (n=85) score higher on ALL VOMS items* than controls (n=85). Symptomatic (n) Smooth Pursuits 33% (28) Horizontal Saccades 42% (36) Vertical Saccades 38% (32) Vestibular Ocular Reflex 58% (49) Visual-Motion Sensitivity 49% (42) Convergence 34% (29) VOR was associated with the highest percentage (58%) of patients reporting symptom provocation AND the highest average number of total endorsed symptoms (3.99) *p< * Smooth Pursuits 2.9 * 2.6 * 4 * 3.5 * Hor. Saccades Ver. Saccades Concussed 6.1 * 1.8 VOR VMS NPC (cm) Controls Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). 20

21 Strongest predictors were: VOR (OR = 4.11) and VMS (OR = 3.62) Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). ALL VOMS symptom scores and NPC distance were significant predictors of being in the concussed group (N=170). Variable Significance Odds Ratio Smooth Pursuit Saccades Horizontal Saccades Vertical NPC (Symptoms) NPC (Distance) Vestibular Ocular Reflex Visual Motion Sensitivity R- Squared < < Increasing Diagnostic Accuracy with Cut-off Scores NPC distance 5 cm = 34% increase in probability of identifying a patient with concussion. A symptom score > 2 on any VOMS item= 46% increase in probability of identifying a patient with concussion. 50% 16% NPC Chance > 5cm 50% 84% VOMS Item Sx > 2 4% 96% Correct Incorrect Correct Incorrect 1 The Diagnostic Accuracy of the VOR, VMS and NPC (adj. for age) for Predicting Concussed Patients is Excellent (.90 [95% CI= ], p<.001). 3 VOMS Items=.90! Dotted line=.50 or no better than chance Vestibular-Ocular Motor Screening (VOMS) Assessment Receiver Operating Characteristic Curve Positive Prediction Rate of 90% Are there Gender Differences on the VOMS? * Model variables: ln(age), VOR, VMS and NPC distance, dotted line indicates AUC =

22 Females (n= 35) report more symptoms on the VOR, VMS, and higher NPC distance than males (n= 50) Vestibular-Ocular Motor Screening (VOMS) Assessment What is the Relationship of the VOMS to PCSS (symptoms), BESS (balance), and ImPACT (neurocognitive function)? Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). VOMS Items Correlate with Total Concussion Symptom Scores on PCSS (N= 85) VOMS is NOT Balance (N= 85) Smooth Pursuit Symptom Score Hor. Saccades Symptom Score Ver. Saccades Symptom Score Correlation with PCSS Total.36*.52*.48* NPC Symptoms.49* NPC Distance.21 VOR Symptoms.44* VMS Symptoms.40* All VOMS symptom scores were moderately positively correlated to PCSS total scores NPC Distance was not correlated to PCSS total score *p<.05 Smooth Pursuit Symptom Score Hor. Saccades Symptom Score Ver. Saccades Symptom Score Correlation with BESS Total Error Score NPC Symptoms.06 NPC Distance.15 VOR Symptoms -.05 VMS Symptoms.11 The average total BESS error score in concussed patients=

23 VOMS Correlates with Computerized Neurocognitive Performance (N= 85) Verbal Memory Visual Memory Process. Speed Reaction Time Smooth Pursuits Hor. Saccades Ver. Saccades VOR VMS NPC Distance -.23* -.26* -.28* * -.26* -.22* -.20* -.30** * -.27* -.25* -.29** * -.27*.40**.31*.33**.20.27*.48** *p<.05, **p<.01 Nearly all VOMS symptom scores and NPC Distance were moderately negatively correlated with ImPACT neurocognitive performance (except VOR) Conclusion Nearly 60% of concussed patients report at least one provoked symptom on the VOMS. The VOMS is a reliable and brief clinical screen for vestibular and ocular motor impairment/symptoms. Females report more symptoms on the VOMS and higher NPC distances. Cut-off for VOMS symptom score (>2) and NPC distance (>5cm) increased diagnostic accuracy 34% and 46% respectively. Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). Conclusion VOR, VMS and NPC Distance items of the VOMS resulted in a 90% positive prediction rate for patients with concussion. The VOMS is related to total concussion symptom scores. The VOMS assesses a construct that is unique from balance following sport-related concussion. The VOMS is related to ImPACT neurocognitive performance following sport-related concussion. Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. (In Review). PART II: Using Concussion Clinical Trajectories to Inform Targeted Clinical Management Pathways: Putting it all Together Micky Collins, PhD Collins MW, Kontos A, et al, KSST,

24 Concussion Clinical Trajectories: A Model for Understanding Assessment, Treatment and Rehabilitation Anxiety/ Mood Cervical Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Clinical Trajectories Determined by: Clinical Interview *Constitutional risk factors *Symptom clusters *What questions to ask? Vestibular-Ocular Screening *Provocative or not? *Specific findings help determine level/type of exertional activity Computerized Neurocognitive Testing *Specific cognitive profiles for specific clinical trajectories Findings lead to individually determined treatment and rehabilitation plan Assessment Vestibular Constitutional risk factors- car sickness/motion sensitivity Symptoms: slow/wavy dizziness, foggy, one-step behind, nausea, feeling of being overwhelmed in high stimulus areas Some Questions to Ask Do busy environments cause you to have a headache or feel foggy, dizzy, anxious, tired? Do you become dizzy when looking up/down, turning head, walking down busy hallways? Do quick movements make you dizzy, foggy, anxious? Vestibular-Ocular Screening symptom provocation VOR (vertical and/or horizontal) Visual motion sensitivity Computerized Neurocognitive Test Results Deficits predominantly with Visual Motor Speed 93 Collins MW, Kontos A, et al, KSST, Collins MW, Kontos A, et al, KSST, 2014 Vestibular Treatment 95 Vestibular therapy Dynamic physical exertion protocol-at end stages of vestibular therapy Pharmacological (done only if there is mood, migraine, sleep overlay) Clonazepam-if anxiety/rumination is present Tricyclics-If migraine overlay SSRIs--mood overlay Melatonin, Trazodone, Zolpidem-if sleep overlay 24

25 97 Anxiety/ Mood Cervical Concussion Clinical Trajectories Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Clinical Trajectories Determined by: Clinical Interview *Constitutional risk factors *Symptom clusters *What questions to ask? Vestibular-Ocular Screening *Provocative or not? *Specific findings help determine level/type of exertional activity Computerized Neurocognitive Testing *Specific cognitive profiles for specific clinical trajectories Findings lead to individually determined treatment and rehabilitation plan Collins MW, Kontos A, et al, KSST, Assessment Anxiety/ Mood Constitutional Risk Factors- Personal/Family hx of Anxiety, entire Engineering profession, Mom of child has thick notebook Symptoms: ruminative thoughts, hypervigilant, fastidious, feelings of being overwhelmed, difficulties initiating/maintaining sleep. Some Questions to Ask How often do you take inventory on your symptoms? Do you have a difficult time turning off your thoughts? Do you become symptomatic when thinking about your symptoms? Have social activities been restricted? How often do your parents ask about your symptoms? Vestibular-Ocular Screening symptom provocation Normal or only mildly provocative (more provocative if vestibular overlay) Computerized Neurocognitive Test Results NORMAL- if no vestibular component If vestibular component-deficits with Visual Motor Speed (treat vestibular component first!!) Collins MW, Kontos A, et al, KSST, 2014 Treatment Anxiety/ Mood Supervised Exertional Therapy (if vestibular component resolved)-push them hard!! Grandma Talk! (Regulated schedule, sleep, exercise, diet, hydration, stress) Psychotherapy Pharmacological Antidepressants SSRIs Benzodiazepines Clonazepam Anxiety/ Mood Cervical Concussion Clinical Trajectories Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Clinical Trajectories Determined by: Clinical Interview *Constitutional risk factors *Symptom clusters *What questions to ask? Vestibular-Ocular Screening *Provocative or not? *Specific findings help determine level/type of exertional activity Computerized Neurocognitive Testing *Specific cognitive profiles for specific clinical trajectories Findings lead to individually determined treatment and rehabilitation plan Collins MW, Kontos A, et al, KSST,

26 Exam Type Post-Injury Date Tested 10/12/12 Assessment Ocular Constitutional Risk Factor- Personal/Family hx of ocular dysfunction Symptoms: Frontal headache, fatigue, distractible, difficulties with visually based classes, pressure behind the eyes, focus issues Some Questions to Ask Do you feel a frontal pressure in your head /behind eyes when reading/computer work/taking notes in class? Do you have blurred or fuzzy vision while reading or difficulty reading? Are you having more significant difficulty in Math and/or Science? Computerized neurocognitive test results Deficits with Visual Memory, Reaction Time Deficits with encoding rather than retrieval Vestibular Ocular Screening symptom provocation Pursuits/Saccades Near Point of Convergence (>5cm) 101 Collins MW, Kontos A, et al, KSST, 2014 Word Memory WG = 1 Hits (immediate) 6 Correct distractors (immed.) 6 Learning percent correct 100% Hits (delay) 6 Correct distractors (delay) 9 Delayed memory pct. Correct 57% Total percent correct 61% Design Memory Hits (immediate) 5 Correct distractors (immed.) 6 Learning percent correct 71% Hits (delay) 7 Correct distractors (delay) 8 Delayed memory pct. Correct 50% Total percent correct 67% X's and O's Total correct (memory) 6 Total correct (interference) 115 Avg. correct RT (interference) 0.71 Total incorrect (interference) 7 Avg. incorrect RT (interfer.) 0.37 Symbol Match Total correct (visible) 27 Avg. correct RT (visible) 1.89 Total correct (hidden) 4 Avg. correct RT (hidden) 1.06 Color Match Total correct 9 Avg. correct RT 0.92 Total commissions 1 Avg commissions RT 0.57 Three Letters Total sequence correct 3 Total letters correct 11 Pct. Of total letters correct 71% Avg. time to first click 1.95 Avg. counted 13.2 Avg. counted correctly Treatment Ocular Vestibular therapy with ocular-motor focus (if NPC < 20cm) Vision therapy (if NPC > 20cm or other complicated presentation) Dynamic physical exertion protocol (isolated binocular dysfunction will not result in symptoms with dynamic exertion) Anxiety/ Mood Cervical 103 Concussion Clinical Trajectories Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Clinical Trajectories Determined by: Clinical Interview *Constitutional risk factors *Symptom clusters *What questions to ask? Vestibular-Ocular Screening *Provocative or not? *Specific findings help determine level/type of exertional activity Computerized Neurocognitive Testing *Specific cognitive profiles for specific clinical trajectories Findings lead to individually determined treatment and rehabilitation plan Collins MW, Kontos A, et al, KSST, 2014 Assessment Cognitive/ Fatigue Constitutional Risk Factor-Hx of Learning Disability Symptoms: fatigue, general headache, end of day symptoms, may have sleep deficits Some Questions to Ask Do you have a generalized headache that increases as day progresses? Do you feel more fatigued than normal at the end of the day? Do you feel more distractible in school than normal? Vestibular-ocular screening symptom provocation Normal Computerized Neurocognitive Test Results Global mild deficits across all composites Deficits with retrieval rather than encoding 104 Exam Type Post-Injury Date Tested 09/03/12 Word Memory WG = 1 Hits (immediate) 12 Correct distractors (immed.) 12 Learning percent correct 100% Hits (delay) 11 Correct distractors (delay) 8 Delayed memory pct. Correct 79% Total percent correct 90% Design Memory Hits (immediate) 12 Correct distractors (immed.) 11 Learning percent correct 84% Hits (delay) 9 Correct distractors (delay) 9 Delayed memory pct. Correct 62% Total percent correct 73% X's and O's Total correct (memory) 8 Total correct (interference) 115 Avg. correct RT (interference) 0.45 Total incorrect (interference) 7 Avg. incorrect RT (interfer.) 0.37 Symbol Match Total correct (visible) 27 Avg. correct RT (visible) 1.19 Total correct (hidden) 8 Avg. correct RT (hidden) 1.06 Color Match Total correct 9 Avg. correct RT 0.78 Total commissions 1 Avg commissions RT 0.57 Three Letters Total sequence correct 3 Total letters correct 11 Pct. Of total letters correct 71% Avg. time to first click 1.95 Avg. counted 13.2 Avg. counted correctly

27 Treatment Cognitive/ Fatigue Physical/Cognitive Breaks throughout day (no naps) Monitored exertional progression Pharmacological Amantadine Methylphenidate Sleep aid if indicated Cognitive Therapy if protracted Anxiety/ Mood Cervical Concussion Clinical Trajectories Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Clinical Trajectories Determined by: Clinical Interview *Constitutional risk factors *Symptom clusters *What questions to ask? Vestibular-Ocular Screening *Provocative or not? *Specific findings help determine level/type of exertional activity Computerized Neurocognitive Testing *Specific cognitive profiles for specific clinical trajectories Findings lead to individually determined treatment and rehabilitation plan Collins MW, Kontos A, et al, KSST, 2014 Assessment Post- Traumatic Migraine Constitutional Risk Factor- Personal or family hx of migraine Symptoms: Variable headache and intermittently severe Nausea with Photo and/or phono-sensitivity Stress, anxiety, lack of exercise, dysregulation May present with vestibular-migraine symptoms Some Questions to Ask Did you get migraines before injury? Is your sleep dysregulated? Do headaches occur after poor sleep? Are you experiencing more stress than normal Vestibular-Ocular Screening symptom provocation Normal (abnormal if vestibular component present) Computerized Neurocognitive Test Results Verbal and Visual Memory deficits (if vestibular component present-speed deficits as well) 107 Collins MW, Kontos A, et al, KSST, Post- Traumatic Migraine Treatment Pharmacological Tricyclic Antidepressants Amitriptyline Anticonvulsants Migraine abortives Imitrex, Maxalt Increased cardiovascular activity-get them active! Grandma Talk -Regulation! 1 Regulated Sleep 2 Hydration 3 Regulated diet 4 Reduce Stress 5 Exertion/Activity 27

28 Case Example Collegiate Hockey Player Concussion Clinical Trajectories Anxiety/ Mood Cervical Vestibular Concussion Clinical Trajectories Determined by: Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing Ocular Cognitive/ Fatigue Post- Traumatic Migraine Hit Video September 25, 2012 Brief loss of consciousness, 2 hour PTA, 45 second retrograde amnesia Spine-boarded and transported to hospital-ct unremarkable Attempted return to school 1 week later Significant symptoms of frontal headache, fatigue, academic difficulties, mood changes Removal from school for remainder of academic year Told to rest with no physical activity No Other significant medical history Referred to UPMC Concussion Program 28

29 UPMC Vestibular-Ocular Motor Screening Form (UPMC VOMS) UPMC Evaluation November 5, 2012 (6 weeks post injury) Convalescing at home-no exertion allowed Previously underwent local vestibular evaluation and determined vestibular therapy not warranted Significant symptoms of fatigue (8/10 daily), frontal headache (7/10 daily), difficulties with focus, mood concerns (irritability, concern, dysphoria). Headache/fatigue increased with reading and computer work UPMC Assessment and Evaluation Clinical Interview Computerized Neurocognitive Testing Vestibular-Ocular Exertional Testing Neck Mucha, Collins, Kontos, Troutman Elbin, Data under review 29

30 Testing November 5, 2012 Smooth pursuits, saccades, gaze stability, optokinetic stimulation, balance WNL Near point of convergence = 22cm Convergence insufficiency Marked right side exophoria Exertional testing WNL Ecstatic with working out-mood improved immediately Neck Evaluation WNL Impaired computerized neurocognitive data Baseline 9/02/2011 Post-Injury 1 11/05/2012 Convergence Insufficiency Hit Video Recommendations for November 5, 2012 evaluation Vision therapy through Behavioral Optometry No restrictions on exertion-full conditioning Become socially active Limited reading, computer work during initial stages of vision therapy Prognosis excellent for resolution of symptoms/deficits/return to play with treatment (10 weeks) 30

31 Follow-up evaluation December 28, 2012 (3 months post injury-7 weeks after first eval) Patient improving significantly One headache per week (2/10-30 minutes in duration); fatigue/mood issues resolved No other symptoms endorsed Patient involved in full aerobic activity, lifting, skating- Stage 5 hockey-specific activity with no contact Testing December 28, 2012 Computerized neurocognitive testing Near point convergence improved from 22 cm to approximately 9 cm Right-side exophoria still present Baseline Post-Injury 1 9/02/ /05/2012 Post-Injury 2 10/28/2012 Recommendations for December 28, 2012 Finish vision therapy Return after vision therapy and prior to school year for clearance Continue exertional activity with no restriction 31

32 Final evaluation June 20, 2013 (9 months post injury) Had felt 100% since mid-feb 2013 Exertional testing WNL Finished vision therapy (Feb)-NPC = 4 cm Baseline Post-Injury 1 Post-Injury 2 Post-Injury 3 9/02/ /05/ /28/2012 6/20/2013 Computerized Neurocognitive Testing Final Interview Video Case Example: NFL Defensive Back 32

33 Past medical history unremarkable - no prior concussion history August 11, 2012 Hit helmet to helmet in left temporal region Loss of consciousness briefly (seconds) 30 minutes of retrograde amnesia, 90 minutes post-traumatic amnesia - overt confusion and initial vomiting Hospitalized 3 day inpatient stay Continual vomiting Severe headaches, photosensitivity, fatigue, cognitive deficits Initial CT scan unremarkable August 16, 2012 Meets with team physician Flattened affect, slowed speech, intact reflexes Ordered MRI of brain - revealed contusion in posterior temporal area of left hemisphere September 12, 2012 Second MRI revealed small focus of low attenuation in left temporal area Less notable than first MRI Continued experiencing headaches, dizziness, emotional changes, fatigue, fogginess, sleep problems Referred to UPMC Concussion Program by team physician Evaluation 10/17/2012 at UPMC (2 months postinjury) Left occipital and bilateral temporal headache; 6/10 in severity; 7/7 days per week Blurred and double vision when reading Moderate sleep deficits and fatigue Dizziness which triggers nausea, irritability, headache, fogginess More noticeable in busy places Everyone in grocery store moving around me quickly, Car rides make me sick Wife significantly concerned regarding emotional changes 33

34 Vestibular and Neurocognitive Testing 10/17/2012 Gaze stability and optokinetic sensitivity highly provocative for dizziness and fogginess Both tests produced immediate anxiety and emotionality Saccadic eye movements (vertical/horizontal) cause moderate frontal headache Near point convergence measured at 26 cm ImPACT neurocognitive testing Recommendations for 10/17/2012 evaluation: Post-Concussion Syndrome Targeted treatments Vestibular Therapy to address optokinetic sensitivity/gaze instability Vision Therapy to address convergence insufficiency Exertional Therapy - Stage 1 Prescribed Pharmacological Intervention 5 mg Ambien to address sleep problems 100 mg Amantadine twice daily to address fatigue/cognitive deficits 34

35 Follow-up Evaluation 11/29/2012 Compliant with all therapies Amantadine twice daily, no longer on Ambien Vestibular screening normal Near point of convergence 9cm (previously 26cm) 6 weeks of vision therapy remaining Progressed to Stage 5 of exertional therapy 14 Year Old Sophomore 3.4 High School GPA ; Standardized testing Average-High Average range Medical History No prior concussion/neurologic history Hx of migraine - onset at age 12, no formal tx Strong family history of migraine Concussion sustained 10/20/11 35

36 October 11, 2011 Base Cheerleader - hit by teammate, fell to ground, striking face off floor Epistaxis - focus on nose No LOC, no retrograde amnesia, 30 second period of PTA/confusion Acute symptoms of bilateral blurred vision, dizziness, nausea, moderate headache, fatigue Mom took to ED - CT conducted - unremarkable That evening, car ride home increased symptoms of headache, fatigue, fogginess, feeling detached, feeling anxious Subsequently managed by pediatrician for 6 weeks, light academic accommodations, no sports allowed No improvement in symptoms Referred for evaluation at UPMC Evaluation 11/28/11 (5 weeks post injury) Clinical/symptom interview Headaches 7/7 days, 8/10 severity with associated photo/phonophobia, dizziness, nausea, difficulties with sleep, fatigue Much more irritable as reported by parents Vestibular screening Provoked with horizontal saccades and horizontal gaze stability, VOR cancellation NPC = 11cm ImPACT Testing Referral to Vestibular Therapy Avoid busy environments, avoid long car rides, avoid heavy ocular activity ½ days of school - full accommodations (ocular and vestibular-based) Return evaluation in 3 weeks - Return Evaluation 12/27/11 (2 months post injury) Had attended 1 session of vestibular therapy and discontinued Half-days of school very helpful Minimal symptoms - mild headaches 2/7 days, mild fatigue Vestibular exam much improved - mild provocation; NPC WNL ImPACT Testing Recommended full days of school, exertional progression, reeval for clearance - Return Evaluation 02/14/12 Stated she was normal - Headaches 1/14 days, no other sx Full exertion with no increase in sx ImPACT testing Rx clearance back to low-risk activity Rx final follow up in 1 month for closure on case/full clearance 36

37 - Return Evaluation 05/24/12 Never followed up with clearance eval New injury 05/19/12 - Hit in larynx by teammate while cheering - No mental status change but immediate headache, dizziness, nausea Was attending school - severe headaches, dizziness, nausea, fogginess, sleep deficits, moderate anxiety/emotional sequelae Playing on phone until 2am, sleeping 4 hours per night Vestibular Exam ImPACT Testing Out of school for 10 days/vestibular therapy /Vision therapy referrals/out of cheering 37

38 - Return Evaluation 07/13/12 Finished Vision therapy Finished Vestibular therapy Reported 100% symptom free - last headache 2 weeks prior Excellent compliance with regulated sleep schedule, hydration, diet, exercise ImPACT testing Stage Stage 1 Target Heart Rate : 30-40% of maximum exertion 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. Recommendations: exercise in quiet area (treatment rooms recommended); no impact activities; balance and vestibular treatment by specialist (prn); limit head movement/position change; limit concentration activities; minutes of light cardio exercise Activity - Very light aerobic conditioning - Static balance activities - Limit head movement (weight machines, squats/lunges with focusing) - Core exercises without head movements Stage 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 4 (Sports Performance Training) Target Heart Rate: 80-90% of maximum exertion Recommendations: continue to avoid contact activity, resume aggressive training in all environments Activity - Non-contact physical training - Aggressive strength exercise - Impact activities/ plyometrics - Sports specific training activities Stage 2 Target Heart Rate : 40-60% of maximum exertion Recommendations: exercise in gym areas recommended; allow some positional changes and head movement; low level concentration activities (counting repetitions); minutes of cardio exercise - Light to moderate aerobic conditioning - Balance activity with head movement - Resistance exercises with head movements (e.g. lateral squats with head movement) - Low intensity sport specific activity - Core exercises with head movement (e.g. side planks with arm/head turn, bicycles, Russian Twists) Stage 5 (Sports Performance Training) Target Heart Rate: Full exertion Recommendations: initiate contact activities as appropriate to sport activity; full exertion for sport - Resume full physical training activities with contact - Continue aggressive strength/ conditioning exercise - Sport specific activities Stage 3 Target Heart Rate: 60-80% of maximum exertion Recommendations: any environment okay for exercise (indoor/outdoor); integrate strength, conditioning, and balance/proprioceptive exercise; can incorporate concentration challenges (counting exercises, visual games) - Moderately aggressive aerobic exercise (intervals, pyramids, stair running) - All forms of strength exercise (80% max) - Dynamic warmups - Impact activities running, plyometrics (no contact) - Challenging positional changes (burpees, mountain climbers) - More aggressive sports-specific activities 38

39 Case Example Major League Baseball Catcher Case Example: MLB Catcher 27 year-old-mlb player (Catcher) Medical history-remarkable for four prior concussions 2003-Beaned by fastball-reported symptoms for 7 days then RTP 2005-Beaned by fastball-symptoms for 5 days then RTP 2008-Foul tip to facemask while catching-symptoms 15 days then RTP 2010-Foul tip to facemask while catching-symptoms 30 days then RTP Tendency for foul tips to produce dizziness, vision changes, headaches, foggy -never taken out of play Idiopathic issues with vision for 6 weeks-visited opthamologist-no formal diagnosis or treatment recommendations History of motion sensitivity (car sickness) as child No other medical or psychiatric history Academic history-did well in limited schooling-no history of LD or ADD Drafted at Age 16 from Venezuela Concussion sustained 03/11/12 Case Example: MLB Catcher March 11, 2012 Foul tip to facemask while catching-linear blow Acute symptoms of dizziness, bilateral blurred vision, feeling detached Symptoms worsened over next three innings, told ATC and removed from game Sent to Emergency Room-CT Scan of head, X-ray of neck unremarkable Rested for 3 weeks with minimal improvement Continued to report headaches (8 hours per day; 6/10 severity), moderate levels of photosensitivity, phonophobia, fatigue, fogginess, cognitive deficits, significant sleep concerns, emotional flatness Referred to UPMC Concussion Program on 04/04/12 (3.5 weeks post injury) Case Example: MLB Catcher-History of four prior concussions and event on March 11, 2012 UPMC Evaluation April 4, 2012 Clinical Interview All symptoms persistent and severe across vestibular, ocular, cognitive, mood, sleep domains Vestibular-Ocular Examination NPC (Near Point of Convergence = 27cm) Significant provocation with vertical and horizontal VOR Significant provocation with Visual Motion sensitivity Exertional Testing Only able to tolerate stationary bike for 15 minutes Unable to tolerate more dynamic activity No other exertional testing due to severity of provocation Computerized Neurocognitive Testing Severe deficits with Reaction Time, Visual-Motor Speed-moderate deficits with Verbal and Visual Memory 39

40 Case Example: MLB Catcher Impressions-Chronic post-concussion syndrome from recent and prior mtbi s 2011 symptoms likely post concussive in nature Difficulties chronic Symptom concerns-vestibular, Ocular, Cognitive, Anxiety April 4, 2012 Treatment Recommendations Targeted Vestibular therapy Vision therapy (HTS program) for convergence insufficiency Exertional therapy (stationary bike, core work, strengthening-quiet gym) PMR-prescribed Amantadine, Ambien, Clonazepam, Monthly follow-up appointments at UPMC Concussion Clinical Trajectories: A New Model for Understanding Assessment, Treatment and Rehabilitation? Anxiety/ Mood Cervical Vestibular Concussion Post- Traumatic Migraine Ocular Cognitive/ Fatigue Case Example: MLB Catcher August 7, 2012 Clinical interview Had progressed significantly with Vision, Vestibular and Exertional therapies Reported being 95%-no physical symptoms reported-sleep/mood WNL Had discontinued Ambien/Klonopin (continued on Amantadine) NPC=3cm; All Vestibular-Ocular testing WNL Computerized neurocognitive testing improved significantly Recommended progression to baseball activities, continue with exertional training (discontinue vestibular, vision therapies) Wean off meds Return for clearance September 6, 2012-Final Evaluation 100% asymptomatic, off all medications, Neuroocognitive data WNL Full clearance to Winter League Baseball Now playing successfully in Major Leagues 40

41 Thank you 41