Basis for Our Research

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Lionel Caldwell
5 years ago
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1 The Concussion Discussion: An Evidence Based Approach to Clinical Decision Making for Mild Traumatic Brain Injury Basis for Our Research Clinical Outcomes and Decision Making Communication and Standard Operating Procedure for Assessment of Potential Head Injury and Management of Concussion Team Approach 1

Goal / Disclaimer of Research Funded by National Institute of Health Goal: Utilizing Expensive (Gold Standard) Tools to Determine Practical / Cost Effective Tools for the

2 Goal / Disclaimer of Research Funded by National Institute of Health Goal: Utilizing Expensive (Gold Standard) Tools to Determine Practical / Cost Effective Tools for the Assessment of Concussion What is not going to be discussed. Focal Injuries Epidural Hematoma Dura Mater Subdural Hematoma Skull Fracture Sideline Assessment Grading Scales 2

3 Goals of The Concussion Discussion Understand the need and methods of developing a scientifically based practical concussion management protocol Understand structural vs. functional brain injuries Foundations of Discussions: Pathology Mechanism Classification Assessment Tools Physiological Assessment (Imaging) 3

4 Focus of Presentation Concussed SMA IPL MFG Control R L Z54 Z45 Z-28 Recommendations from NATA Position Statement 36 Recommendations 7 of which deal with the following: Symptomalogy Postural Assessment / Balance Neuropsychological Assessment 4

5 5 I M a n a g e m e n t m p t o m a l o g y t u r o l o g r a p h y p s y c h o l o g i c a l y s i c a l E x a m Why multiple probes? Why multiple test to determine the integrity of the ACL?

6 Symptomalogy Guideline for Management Mechanisms for Obtaining Symptomalogy Verbal / Interview Component of Computerized Neuropsychological Examination Checklist Scale 6

Use of Symptomalogy Scales / Checklist Objectivity to a Subjective Test Importance of Baseline Provides a Guideline for the Protocol Scale or Checklist Timeline for Testing List of Symptoms Headache

7 Use of Symptomalogy Scales / Checklist Objectivity to a Subjective Test Importance of Baseline Provides a Guideline for the Protocol Scale or Checklist Timeline for Testing List of Symptoms Headache Nausea Sensitivity to Light Sensitivity to Noise Trouble Falling Asleep Sleeping More Ringing of the Ears Balance Difficulty Fatigue Feeling in a Fog Difficulty Remembering Feeling Slowed Down Drowsiness Difficulty Concentrating 7

8 Do you have any of these symptoms presently? 1. Yes 2. No 7% 93% Yes No Checklist Sample Symptom Checklist HEADACHE YES / NO (circle one) NAUSEA YES / NO (circle one) FEELING IN A FOG YES / NO (circle one) FATIGUE YES / NO (circle one) FEELING SLOWED DOWN YES / NO (circle one) DIFFICULTY REMEMBERING YES / NO (circle one) DROWSINESS YES / NO (circle one) SLEEPING MORE YES / NO (circle one) 8

9 Scale Sample Symptom Scale never sometimes always HEADACHE NAUSEA FEELING IN A FOG FATIGUE FEELING SLOWED DOWN DIFFICULTY REMEMBERING DROWSINESS SLEEPING MORE Symptomalogy Case Study Baseline < 24 Hours 48 Hours 72 Hours SRA ASY Day 1 ASY Day 4 9

10 Problems with Symptomalogy Time of Baseline Testing Truthfulness Symptoms as a Whole vs. Individually Coexisting Conditions Dehydration Illness Infections Posturography 10

11 Balance Assessment Balance Error Scoring System Neurocom Wii Fit Concussion Balance Assessment Tool Posturography NeuroCom Smart Balance Master Sensory Organization Test (SOT) 11

Postural Assessment: Example of Sensory Organization Testing Case Study 95

12 Postural Assessment: Example of Sensory Organization Testing Case Study Baseline <24 hrs. post injury SRA ASY ASY Day 4 12

Neurocom: Sensory Organization Testing 20 Min Test

13 Neurocom: Sensory Organization Testing 20 Min Test Baseline Needed? Space Expensive Errors Hands lifted off iliac crests Opening eyes Step, stumble, or fall Moving hip into more than 30 deg. Flex. Or abd. Remain out of testing position greater than 5 seconds Balance Error Scoring System Guskiweicz, et al (JAT, 2001) 13

14 BESS Case Study Baseline < 24 hrs. post injury SRA ASY ASY Day SOT / BESS Comparison Baseline Baseline < 24 hrs. post injury <24 hrs. post injury SRA ASY ASY Day 4 SRA ASY ASY Day 4 14

15 Neuropsychological Testing Traditional & Computerized Purpose of Neuropsychological Testing Function w/ or w/o anatomical (structural) injury Processing Speed Reaction Time Short Term Memory Delayed Recall Importance of Baseline Testing Symbol Digit Modalities Test 15

No Proper Nouns No variations of word Run, runner, running No numbers Five, fifteen, fifty

16 Traditional Neuropsychological Testing Controlled Oral Word Association 60 Seconds to say as many words that begin with? No Proper Nouns No variations of word Run, runner, running No numbers Five, fifteen, fifty Total for all three letters is score Neurocognitive Testing CogState: Headminder: Impact: ANAM: 16

17 What do Computerized Neuropsychological Test do? Short Term Memory Reaction Time Processing Speed Impulse Control Brain Function? Computerized Neuropsychological Case Study Neuro. Psy. Value Baseline Concussed Asy. Day 1 Asy. Day 4 Asy. Day 7 Asy. Day 14 SRT CRT PSI Day 17

18 Neuropsychological Testing with ImPACT Organizing the Tools Pieces of the Puzzle - Guskiweicz 18

Disruption of neuronal function. Impaired neural communication Uncontrolled neurotransmitter release Altered blood flow regulation. Sample Management Protocol baseline < 24 Hrs Day 1 Asy. 1 week Asy.

19 Disruption of neuronal function. Impaired neural communication Uncontrolled neurotransmitter release Altered blood flow regulation. Sample Management Protocol baseline < 24 Hrs Day 1 Asy. 1 week Asy. 1 & 3 Month SX SOT/BESS IMPACT fmri DTI IMPACT Sideline Assessment. Concussed? SX SOT/BESS IMPACT fmri DTI Daily SX NO SX SOT/BESS IMPACT fmri DTI SX SOT/BESS IMPACT fmri DTI SX SOT/BESS IMPACT fmri DTI YES Return to play Resolved? Medical Care 19

20 Timeline Saturday Concussed Sunday PC-1 Monday SRA-1 SX = 26 (BL = 6) SX = 18 (BL = 6) SX = 6 (BL = 6) Balance (-) Neurocog. (+) Balance (-) Neurocog (-) Timeline Saturday Concussed Sunday PC-1 Monday ASY-1 Tuesday ASY-2 SX = 26 (BL = 6) SX = 18 (BL = 6) SX = 6 Balance (-) Neurocog (-) SX = 6 (BL = 6) Balance (-) Neurocog. (+) Stationary Bike Stationary Bike Light Jog 20

21 Timeline Monday ASY-1 Tuesday ASY-2 Wed. ASY-3 Thursday ASY-4 SX = 6 Balance (-) Neurocog (-) SX = 6 (BL = 6) SX = 6 (BL = 6) SX = 6 Balance (-) Neurocog (-) Stat. Bike Stat. Bike Light Jog Running Sport Specific Drills Sport Specific Drills No Contact Timeline Friday ASY-5 Saturday ASY-6 SX = 6 SX = 6 Full Participation Full Participation 21

22 How do we correlate behavioral measures with Brain Function? fmri / DTI Functional MRI / Diffusion Tensor Imaging Control Concussed SMA IP L MFG R Z54 Z45 Z-28 L 22

23 fmri is a measure of the level of blood oxygenation Arterial Side Venous Side Role of Imaging (fmri) Driving a Car 23

24 Types of fmri Testing (Finger Sequencing) Concussed SMA IPL MFG Control R L Z54 Z45 Z-28 Types of fmri Testing (N Back) 0-back 1-back 2-back 3-back B J D A E Q T F D L X Z D F F G R P P T G S U P U L B M B D A L N R T N O J C O 24

25 Legislative Changes Recommendations Legislative Changes - Summary Concussion Management Plan on File SA with S/S are to be removed from activity and not returned to activity on same day 25

26 Statement SA sign a statement stating that they will notify healthcare providers of illness and injuries and to include S/S of MTBI SA presented with educational materials on MTBI On File EAP on file to address MTBI, heat illness, cardiac arrest, etc., Reviewed annually by healthcare providers and coaches 26

27 Authority Healthcare providers empowered to have unchallengeable authority to determine (all illnesses and injuries): Management Assessment RTP No coach as primary supervisor or have sole hiring or firing authority over that provider Management Plan Ensure that coaches of working knowledge / understanding of plan Healthcare providers should practice within their scope and direction 27

28 Baseline Assessment Should record baseline assessment for selected sports. Symptom Checklist Standardized Cognitive Assessment (SAC, SCAT, etc., Balance Assessment (BESS, Neurocom, Wii) Additional, neuropsychological testing ideally interrupted by a neuropsychologist RTP SA with S/S should be removed from activity and evaluated by healthcare provider Not return on same day Serial monitoring and provided written instructions Evaluated by Team MD Once asymptomatic and post-exertion assessments are within normal baseline limits, RTP with a stepwise process Decision by Team MD or designee as outlined in management plan 28

29 Do you have a concussion management plan on file? 1. Yes 2. No Conclusion Multiple Probes in an Organized and Practical Manner Symptomalogy Posturography Neuropsychological Baseline Measures 29

30 Questions or Headache? Thank you! Brian Anderson 30

31 Housekeeping Items Evaluation Forms Interest Forms Clickers Safe travels and hope to see you at a future meeting 31

Concussion. Concussion is a disturbance of brain function caused by a direct or indirect force to the head.

Concussion. Concussion is a disturbance of brain function caused by a direct or indirect force to the head. Concussion Concussion is a disturbance of brain function caused by a direct or indirect force to the head. Disturbances of brain tissue is largely related to neurometabolic dysfunction rather then structural