Diagnostic Tools. Objectives UPDATES AND ADVANCES IN THE DIAGNOSIS AND MANAGEMENT OF SPORTS RELATED CONCUSSION

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UPDATES AND ADVANCES IN THE DIAGNOSIS AND MANAGEMENT OF SPORTS RELATED CONCUSSION Summer D. Ott, Psy.D. Neuropsychologist & Assistant Professor Department of Orthopedics UT Medical School at Houston

1 UPDATES AND ADVANCES IN THE DIAGNOSIS AND MANAGEMENT OF SPORTS RELATED CONCUSSION Summer D. Ott, Psy.D. Neuropsychologist & Assistant Professor Department of Orthopedics UT Medical School at Houston Director, Concussion Program Memorial Hermann Ironman Sports Medicine Institute Objectives Identify tools useful in the diagnosis of concussion Review clinical factors that predict athletes with increased risk for prolonged recovery and chronic effects Discuss interventions that enhance recovery Diagnostic Tools 1

2 Useful Tools in the Identification of Concussed Athletes Tools should not be substitute for thorough medical, neurologic or neuropsychological evaluation Combination of diagnostic tools improve diagnostic accuracy compared to individual tests Tools identify acute impairment but no evidence that to predict chronic neurologic or neurobehavioral impairment Useful Tools in the Identification of Concussed Athletes continued Post Concussion Symptom Scale or Graded Symptom Checklist Evidence to support that PCSS or GSC will accurately identify athletes involved in an event Useful Tools in the Identification of Concussed Athletes Neuropsychological Testing Paper-pencil & Computerized Administration by non neuropsychologist although generally requires a neuropsychologist for accurate interpretation Useful in identifying neurocognitive effects of concussion, relatively good sensitivity and specificity Insufficient evidence to recommend widespread routine use of baseline testing Support for neuropsych testing in preadolescent groups 2

3 Useful Tools in the Identification of Concussed Athletes Standard Assessment of Concussion (SAC) Assess four domains: orientation, immediate memory, concentration and delayed memory recall administration in 6 minutes Likely to identify the presence of concussion in early stages, relatively good sensitivity and specificity Useful Tools in the Identification of Concussed Athletes Balance Error Scoring System Assess postural stability Five minute administration Identify concussion with low to moderate diagnostic accuracy Sensitivity low but specificity high Good test retest reliability Clinical Factors 3

4 CLINICAL FACTORS THAT PREDICT INCREASED RISK FOR LONG TERM EFFECTS Predictors of severe or prolonged early post concussion impairment History of previous concussion=more severe and longer duration of symptoms and cognitive deficits Early presence of post-traumatic headache, fatigue, fogginess, amnesia, and disorientation=persistent neurocognitive problems and prolonged RTP Younger age/level of play=prolonged recovery Prior Hx of headaches = persistent neurocognitive Playing on artificial turf in football= more severe concussions Gender=conflicting evidence CLINICAL FACTORS THAT PREDICT INCREASED RISK FOR LONG TERM EFFECTS Predictors of Recurrent Concussions Increased risk for repeat concussion in the first 10 days after initial concussion supported by pathophysiologic studies Longer length of participation in sport Quarterback position in football CLINICAL FACTORS THAT PREDICT INCREASED RISK FOR LONG TERM EFFECTS Predictors of Neurocognitive Impairment Increased exposure across a broad range of professional sports -Football, soccer, boxing, and horse racing Insufficient evidence to determine whether a relationship exists between cognitive impairment and heading in professional or amateur soccer Data insufficient to determine whether prior concussion exposure is associated with chronic cognitive impairment in amateur athletes (exceptions: Hx of LD, APOE E4 genotype) 4

5 Interventions INTERVENTIONS THAT PROMOTE RECOVERY, REDUCE RE-INJURY, AND LONG TERM EFFECTS Education at all levels/pre-participation Tools and adopted protocol ready Baseline assessment, particularly for those at risk Tackling techniques, Rules, Legislation INTERVENTIONS THAT PROMOTE RECOVERY, REDUCE RE-INJURY, AND LONG TERM EFFECTS Management of Diagnosed Concussion Return to Learn and Return to Play Asymptomatic without medication Conservative management of younger athletes Proper education and credentials for those using assessment tools Proper reliability and validity of tools used, cultural effects Post injury supportive counseling Education and reassurance 5

6 REHABILITATION FOR POST CONCUSSION SYNDROME Few evidence based interventions for addressing prolonged recovery or PCS in athletes, especially in youth Prescribed medications Role of exercise in management of persistent symptoms Supportive evidence non contact aerobic activity may play positive role in rehabilitation (Leddy et al 2010, with adults) In animal studies exercise enhances brain chemicals responsible for neuroplasticity and neurogenesis, reduces neuroinflammation Benefit on depression in adults and helps prevent depression in adolescents and children REHABILITATION FOR POST CONCUSSIVE SYNDROME Vestibular Therapy Gaze stability exercises, mitigate hypersensitivity to head movement and motion intolerance and gait stability exercises Speech Therapy/Cognitive Retraining Incorporation of compensatory strategies No evidence to date that this is effective in mtbi or sports concussion REHABILITATION FOR POST CONCUSSION SYNDROME Cognitive Behavioral Therapy Psycho educational program following injury in adults equated to faster recovery but no studies in youth Mindfulness training Effects of prolonged Recovery on the Family Unit Time off work Taking care of the teenage athlete who is trying to find their independence Siblings receiving less attention Access to Care Qualified providers Insurance issues Telemedicine 6

FUTURE DIRECTIONS There is still a great deal to learn about concussion and its effects Neurocognitive pre- and post-injury assessment deemed the cornerstone. Will it continue to be?

Other studies show no correlation between levels and cognitive deficits or symptoms post concussion though might assist with predicting an abnormal CT scan Athlete concussion exposures:

7 FUTURE DIRECTIONS There is still a great deal to learn about concussion and its effects Neurocognitive pre- and post-injury assessment deemed the cornerstone. Will it continue to be? Biomarkers Genetic testing? Presence of S100β in the blood sign of damage to the blood brain barrier. Elevated levels in head to head impacts (Cleveland Clinic Study 2011). Other studies show no correlation between levels and cognitive deficits or symptoms post concussion though might assist with predicting an abnormal CT scan Athlete concussion exposures: Accelerometers to be a more common place? Neuroimaging such as DTI and fmri more routine in evaluations? IN SUMMARY We cannot prevent all concussions An environment where athletes are encouraged to report their symptoms and sit out Multi-disciplinary TEAM approach to co-manage care A majority of concussed athletes recover within 2 weeks post event Evidenced based guidelines that come from scientific study not what is played out in the media REFERENCE Giza, C. et al. (2013). Summary of evidence-based guideline update: Evaluation and management of concussion in sports. American Academy of Neurology,

8 Summer D. Ott, Psy.D. 8

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