Clinical Profiles and Recovery Trajectories Concussion Management

Transcription

1 Disclosures and Recovery Trajectories Concussion Management I have no disclosures Aimee Custer, PsyD, LP Clinical Sports Neuropsychologist The following slides are property of Aimee Custer, PsyD. Do not duplicate in any way without written permission. Objectives Identify emerging clinical and corresponding treatment options Review emerging research on Explain the importance of a comprehensive approach to concussion management Describe variations in behavioral modifications, social/physical restrictions, and vocational accommodations for each trajectory History University of Pittsburgh Medical Center (UMPC) Model 18 years of clinical experience and research Collins, Kontos, Okonkwo et al., Neurosurg; 2016 Physiologic, vestibulo-ocular and Cervicogenic Targeted treatments Ellis, M., Leddy, J., & Willer, B., (2014). Brain Injury Ellis, M., Leddy, J., & Willer, B., (2014). Brain Injury 1

2 Growing Agreement that Concussion Involves Different /Subtypes Concussions are characterized by diverse symptoms and impairments in function resulting in different clinical profiles and recovery. Collins, Kontos, Okonkwo, et al., Neurosurg; 2016 Factor Analysis: Post Concussion Symptom Scale SAMPLE DETAILS N=1,438 High School/University Athletes 1-7 Days Post-Concussion Foggy Headache Drowsiness Sadness More Emotional Nervous Slowed Down Dizziness Fatigue Injury Characteristics Vomiting Numbness Sensitivity to Light/Noise Difficulty Remembering Difficulty Concentrating Sleep Less Trouble Falling Asleep Kontos, Elbin, Schatz, Covassin, Henry, Pardini, Collins; AJSM, 2012 Anxiety Excessive and persistent worry and/or fear about everyday situations that is difficult to control. Patients may be unable to accurately characterize their feelings of anxiety. May manifest as: Nervousness Somatic symptoms Cognitive rumination Avoidance, Fear of injury Anxiety Feeling overwhelmed Restlessness, Agitation Difficulties concentrating 2

3 10/24/2018 Secondary characteristics Inactivity Academic stress Increased rules or restrictions Reduced social activities Reduced energy/tolerance for stress Removal of coping mechanisms Pressure from Parents or Coaches Risk factors: Personal or FHx of anxiety, Hx of psychiatric meds CNT: Limited to no deficits, high symptom score VOMS: Normal or mildly provocative; unusual symptoms; more symptom provocation with vestibular overlay Education Regulated Schedule Academic Accommodations? Limited restrictions Vestibular Consult/Therapy Supervised Exertion Therapy Psychology and/or Medications Elbin RJ, Schatz P, et al, Curr Treat Options Neurol, 2014 Vestibular Dysfunction 50% report vestibular symptoms post-concussion 43% experience balance impairments Central versus Peripheral Symptoms: POST Risk factors: Motion Sickness, Vestibular Disorder, Hx of anxiety CNT: Deficits in visual motor speed VOMS: increase in symptoms with gaze stabilization and visual motion integration Dizziness Nausea; motion sickness Fogginess Environmental sensitivities Unstable vision Difficulty focusing, remembering Anxiety Reynolds E, Collins MW, et al, Neurosurgery,

4 Education, especially w/ comorbid anxiety or migraine Appropriate academic accommodations Expose/Recover Vestibular Therapy Guided exertion therapy dynamic exertion protocol Medications Ocular Smooth Pursuits: tracking a moving object Saccades: rapidly changing line of sight and focusing object (i.e., reading) Convergence: binocular vision; simultaneously focusing a single object Vestibular-Ocular Reflex: holds image steady during rotational head movements Eye and Head Movements: interaction of eye movements, head movements, and VOR to change line of sight (i.e., gaze) Risk factors: Personal of family hx of binocular dysfunction CNT: Deficits in visual memory and reaction time VOMS: fixation loss with pursuits, Saccadic deficiencies, Convergence Insufficiency, irregular eye movements, eye strain Vestibular Therapy or Occupational Therapy - Emphasis on ocular-motor exercises Vision Therapy of Therapeutic Lenses - Behavioral neuro-optometrist. Can include both office and home based activities Dynamic Physical Exertion Protocol - Isolated Binocular Dysfunction does not typically result in symptoms with dynamic exertion - Limit visual based tasks (i.e., reading, iphone, computer use) - Academic/Work Accommodations Pharmacological - Limit OTC to reduce risk of rebound headaches - Limited options; stimulants sometimes beneficial 4

5 Cognitive Fatigue Cognitive Complaints Concentration (attention, distractibility) Memory (forgetfulness, repeating oneself) Processing Speed (difficulties with multitasking, slowed) Mental Fogginess (one step behind) Additional Symptoms Dull, generalized headache Headache that worsens throughout day Sleep disruption/change Mood related consequences Fatigue Complaints Tiredness with cognitive or physical exertion Decreased endurance and/or energy levels Decreased tolerance for stress Risk factors:hxof LDor ADHD CNT: global suppression of scores, multiple in low average range VOMS: Typically normal, Saccades and NPC fatigue across trials Breaks from cognitive activity throughout the day Temporarily adjust academic schedule to allow for rest periods Modified work/school schedule Exertion Therapy Monitored exertional progression Cognitive Therapy For cases of protracted recovery Pharmacological Intervention Neuro-stimulants; sleep aids Caffeine Post-Traumatic Migraine Headache with light or noise sensitivity and/or nausea that worsens with exertion, caused by traumatic injury to the head Research indicated that PTM is associated with cognitive deficits and protracted recovery Risk factors: PHx/FHx Migraine, comorbid anxiety, female sex CNT: Deficits in Verbal and Visual Memory VOMS: Typically normal; possible headache provocation. Dizziness or nausea provoked with vestibular overlay Headaches present upon wakening, intermittent throughout day Can be accompanied by dizziness, visual changes, environmental sensitivities, secondary cognitive difficulties Kontos, A, Elbin, R.J., Lau, B, et al., Am J Sports Med,

6 Profile Combinations Behavioral management Regulated sleep, diet, hydration, exercise, stress Stress management Academic Accommodations Pharmacological considerations/supplements PT considerations Neck Exertion Primary Secondary Tertiary References: Thank You! Collins, M.W., Kontos, A.P., Reynolds, E. et al. Knee SurgSports Traumatol Arthrosc(2014) 22: Collins, M.W., Kontos, A., Okonkwo, D.O., Almquist, J., Bailes, J. et al., (2016). Concussion is treatable: Statements of agreement from the targeted evaluation and active management (TEAM) approaches to treating concussion. Neurosurgery, 79(6): Elbin, R. J., Schatz, P. Lowder, H. B., & Kontos, A. (2014). An empirical review of treatment and rehabilitation approaches used in the acute, subacute, and chronic phases of recovery following sport related concussion. Current Treatment Options in Neurology, 16: 320. Ellis, M.J., Leddy, J.J., & Willer, B. (2014). Physiological, vestibule-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Injury, Kontos, A., Elbin, R. J., Lau B., et al. (2013). Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. American Journal of Sports Medicine, 41(7): Kontos, A., Elbin, R.J., Schatz, P., Covassin, T., Henry, L., Pardini, J. Current treatment (2012). A revised factor structure for the post-concussion symptom scale: baseline and postconcussion factors. American Journal of Sports Medicine, 40: Photos that are not cited are public domain Commons.Wikimedia Special Thank You to Dr. Micky Collins and Dr. Anthony Kontos for data provided 6