Clinical Practice of a Vision Based Concussion Tool MATT FRANTZ, M.ED., LAT, ATC LAFAYETTE COLLEGE

Transcription

1 Clinical Practice of a Vision Based Concussion Tool MATT FRANTZ, M.ED., LAT, ATC LAFAYETTE COLLEGE

2 Disclosure No financial COI No non-financial COI No corporate bias or sponsorship

3 Your Concussion Toolbag SCAT 2, SCAT 3 BESS ImPACT Symptom Score, Memory Recall Balance Symptom Score, Memory Recall King-Devick Test Rapid Number Naming and Saccades

4 Vision Based Assessment Tool King-Devick Video-oculography Portable head set DVAT Dynamic Visual Acuity Test

5 Why look at vision? Some Visual tools look at Pursuit Saccades Rapidly shifting horizontal gazes Complex cognitive process including assessment of the stimulus with goals and intentions Reflexive Saccades Anticipatory Saccades Memory guided Saccades Ventura RE, Balcer LJ, Galetta SL. The neuro-ophthalmology of head trauma. Lancet Neurol 2014; 13:

6 Why look at vision? Anti-saccades Measured by having patient try to look away form the stimulus (needs the inhibition of reflexive saccades) Conversion Binocular eye movement in opposite direction to maintain a fusion Near point conversion Ventura RE, Balcer LJ, Galetta SL. The neuro-ophthalmology of head trauma. Lancet Neurol 2014; 13:

7 Why look at vision? Ventura RE, Balcer LJ, Galetta SL. The neuro-ophthalmology of head trauma. Lancet Neurol 2014; 13: Visuospatial information is relayed from the occipital lobe and then processed in the posterior parietal cortex. Cranial Nerve II Cranial Nerve III Cranial Nerve IV Cranial Nerve VI OPTIC OCULOMOTOR TROCHLEAR ABDUCENS

8 Vision Based Assessment Tool EBP EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care.

9 Clinical Question PICO Patient, Population, or Problem Collegiate Athletes Intervention Vision Tools Comparison/Control Concussion group vs control Outcome Relevant patient outcomes

10 Clinical Question What vision based assessment tool is best for assessing sideline concussion in college athletes?

11 The search Use of AND Use of OR Search for Meta-analysis Level 1 Meta-analysis Level 2 RCT Level 3 Non-randomized Clinical Trial Level 4 Case-control or Case Series Level 5 Case Study, Expert Opinion

12 Vision Based Assessment Tool Critical appraisal 1. Makdissi et al. Computerised cognitive assessment of concussed Australian Rules footballers Br J Sports Med Oct; 35: Leong et al. The King-Devick test for sideline concussion screening in collegiate football. J Optom Apr-Jun;8: Pierce et al. Near Point of Convergence After a Sport-Related Concussion: Measurement Reliability and Relationship to Neurocognitive Impairment and Symptoms. Am J Sports Med Dec;43:

13 Vision Based Assessment Tool Critical appraisal Makdissi et al. Computerised cognitive assessment of concussed Australian Rules footballers Br J Sports Med Oct; 35: Digit Symbol Substitution Test (DSST) Trail Making Test-Part B Computerised cognitive test battery (CogState) Low n 3 tests Tests for cognitive function

14 Vision Based Assessment Tool Critical appraisal Leong et al. The King-Devick test for sideline concussion screening in collegiate football. J Optom Apr-Jun;8: College football and M&W basketball One test Sideline for SRC 2015 n=11 High level of test-retest reliability Level 4

15 Vision Based Assessment Tool Critical appraisal Pierce et al. Near Point of Convergence After a Sport-Related Concussion: Measurement Reliability and Relationship to Neurocognitive Impairment and Symptoms. Am J Sports Med Dec;43: Level 3 SRC Seen in mean / days after SRC 42% of subjects had C.I. within 1 month post inj Large time interval Ath with worse CI had higher symptom scores 1/3 of n had previous concussions Prior CI?

16 How do we correctly identify with KD? Sensitivity vs Specificity Sensitivity the ability to correctly identify those with concussion Specificity The ability to correctly identify those without concussion

17 How it works 2015 Study: Baseline of KD, SAC, and tandem balance Youth ice hockey & lacrosse n= 243 NYU & LIU college athletes n= concussions (average score worsened by 5.2 secs) Sensitivity 75% Specificity 93% Galetta KM, et al. Adding vision to concussion testing: A prospective study of sideline testing in youth and collegiate athletes. J Neuroophthamol Sep;35(3):235-41

18 How it works 2015 Study: Baseline of New Zealand Rugby teams n=36, n=35, n=33 KD & SAC Found corresponding worsening KD times with every 1 pt SAC (total SAC score = 1.7sec increase) Sensitivity 100% Specificity 94% King D, et al. The King-Devick test was useful in management of concussion in amateur rugby union and rugby league in New Zealand. J Neurol Sci. 2015; 351 (1-2):58-64.

19 How it works Meta-analysis Galetta KM, Liu M, Leong DF, et al. The King-Devick test of rapid number naming for concussion detection: meta-analysis and systematic review of the literature. Concussion. 2015; 15.8 n=1419 Football, soccer, lacrosse, rugby, boxing, MMA, hockey, basketball Weighted baseline of 43.8 seconds Sensitivity 86% 96/112 concussed athletes showed worsening Specificity 90% 181/202 controls had no worsening

20 K-D as a complement Marinides Z., Galetta K.M., Andrews C.N. Vision testing is additive to the sideline assessment of sports-related concussion. Neuro Clin Pract published online 9 July. U of F FB, WSOC, WLX All had baselines of K-D, PCS (postconcussion scale), SAC (standardized assessment of concussion), BESS, and Immediate Post Concussion Assessment and Cognitive Test (ImPACT) n=217 n=29 79% K-D sensitivity (worsening from baseline to Post) 23/29 52% SAC sensitivity (worsening by 2 pts) 15/29

21 K-D as a complement Combining the K-D and SAC captured 89% (25/28) When BESS added, 100% of concussions were identified. Study states that longer K-D times were associated with reduced ImPACT visual motor speed and visual memory. Marinides Z., Galetta K.M., Andrews C.N. Vision testing is additive to the sideline assessment of sports-related concussion. Neuro Clin Pract published online 9 July.

22 K-D as a complement Galetta KM, et al. Adding vision to concussion testing: A prospective study of sideline testing in youth and collegiate athletes. J Neuroophthamol Sep;35(3): LIU, NYU & Youth sports ROC Curve AT s had 92% (0.92) probability of distinguishing concussed vs non-concussed control groups based on KD alone Timed tandem gait 0.87 SAC.68 Combination of timed tandem gait, SAC & KD = 0.97 ROC curve area

23 Vision Based Assessment Tool Clinical application Clinical expertise Evidence Has high test-retest reliability 0.97 Galetta KM, et al. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology 2011;76: Leong DF, et al. The King-Devick test as a concussion screening tool administered by sports parents. J Sports Med Phys Fitness 2014; 54:70-77 Patient Preference

24 How it works Test that evaluates saccades and attention, and language Baseline Memorizing prompts Q

25 Courtesy King-Devick

26 How it works Lafayette average baseline: LC baseline n=356 Mean =

27 How it works Sideline Locker room Keeping scores with you

28 Courtesy of King- Devick

29 How it works Predispositions / Things to look for: Hx of Concussion Visual Disorders Corrective Vision Learning Disability Negatives Learning Curve Re-test? Versions

30 Spiral-Bound vs. Computerized Raynowska J, et al. Agreement of Spiral-Bound and Computerized Tablet version of the King-Devick Test of Rapid Number Naming for Sports Related Concussion. Ann Sports Med & Res 2015; 2(9): 1051 n= 85 Mean times: Tablet seconds Spiral Bound 48.6 sec Had linear correlation of r=0.94 Remember post concussion is 4-6 sec added

31 King-Devick Research bias

32 Vision Based Assessment Tool Other uses for King-Devick Reading training Chronic concussion training Neurological Function Eye tracking software

33 Vision Based Assessment Tool Create your own clinical question Slide presentation can be found online. Goleopards.com/sportsmedicine