5/19/2017. Concussion: Advancement in Diagnostic & Management Practices

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1 Concussion: Advancement in Diagnostic & Practices Jacob E. Resch, Ph.D., AT Exercise Sport and Injury Laboratory Department of Kinesiology The University of Virginia If it has become cheaper to produce a new invention, this suggest we are using our information wisely and are forging it into knowledge. If it is become expensive, this suggest that we are seeing signs in the noise and wasting our time on false leads. - Nate Silver 1

2 Measurement Properties Objectivity Reliability Validity Inter-rater Reliability (0 1.0) Test-Retest Reliability (0 1.0) Sensitivity & Specificity (0% - 100%) 1 2 Concussion Healthy Clinical of Sport Concussion Clinical Time Interval R ICC Authors Variable Valovich McLeod et al, 2006 Galetta KM et al, 2011 Neurocognitive Putukian et al, day / 2 years Barr, 2003 Segalowitz et al, 2007 Register-Mihalik et al, 2012 Cernich et al, 2007 Resch et al, In Press Falleti et al, 2006 Straume-Naesheim et al, 2005 Collie et al 2003 Broglio et al, 2007 Schatz, 2009 Elbin, 2011 Resch et al, 2013 Nakayama et al, 2014 Gualtieri et al, 2006 Balance 2 days / 58 days Wrisley et al, 2007 Tsang et al, 2004 Symptom Scales / Checklists Warren et al, In Preparation Valovich-McLeod et al, 2006 Ross et al, days.55 Valovich-McLeod,

3 Clinical of Sport Concussion Clinical Measure Sensitivity Specificity Reference 80% - 94% 76% - 91% Barr et al, 2001 Valovich McLeod et al, 2006 McCrea et al, 2005 McCrea M et al, 2003 Valovich McLeod et al, 2004 Naunheim et al, 2008 Grubenhoff JA et al, 2010 Putukian et al, 2016 Neurocognitive Balance Symptom 1% 95% 69.1% - 100% Schatz et al, 2006 Broglio et al, 2007 Van Kampen, 2006 Resch et al, 2016 Schatz et al, 2012 Register-Mihalik et al, 2012 Makdissi et al, 2010 Nelson et al, % % 77% - 91% Broglio et al, 2007 Broglio et al, 2008 Resch et al, 2016 Register-Mihalik et al, % - 89% 85% - 100% Valovich-McLeod, 2012 Resch et al, 2016 Multidimensional Approach to Sport Concussion (Resch et al, 2016) Multifaceted Approach to Sport Concussion % of Surveyed Athletic Trainers Acute Year Notebaert et al, 2005 Lynall et al, 2013 Buckley et al, 2015 RTP 3

4 Clinical of Sport Concussion $$ Time & Ease Cost? $$$ (Vision) Commonly Reported (%) Visual Disturbances in Collegiate Athletes Smooth Pursuits 33% Visual Disturbance Convergence Vertical Saccades Horizontal Saccades Visual Motion Sensitivity 34% 38% 43% 48% Vestibular Ocular Reflex 58% 0% 10% 20% 30% 40% 50% 60% 70% (%) of Collegiate Athletes Mucha et al,

5 (Vision) Pupillometry Video-oculography Pupil Constriction Saccades Horizontal Vertical Pursuit Tasks Anti-saccades Memory Ventura et al, 2015 (Vision) (Balance & Cognition) Sway Balance Phone/iPad-based Balance Error Scoring System Modified Foot placement Surface Use of cell phone/ipad Tri-axial accelerometer (0 100) Reaction Time 5 trials Reaction Time Variability ( 0 100) 5

6 (Balance & Cognition) C3 Logix ipad-based Accelerometer & Gyroscopic data Cognition Standardized Assessment of Concussion (SAC) Trails A&B Symbol Digit Modalities Test Reaction Time Balance Balance Error Scoring System (BESS) Symptoms Visual Acuity Vestibulo-ocular reflex (VOR) (Cognition) Clinical RT Puck Drop Test Measuring stick (1.3 m long) High friction tape 0.5 cm increments Weighted rubber disk Procedures Placed between 1 st and 2 nd digits Released at randomized 2 5 second intervals Trials 2 practice 8 actual (Eckner et al, 2010) Measurement Properties of Tests Test Objectivity Reliability Sensitivity Specificity References Video Oculography King-Devick * 53% - 100%* 69%-94%* Galetta et al, 2011 Galetta et al, 2011 King et al, 2015 King et al, 2015 Molloy et al, 2017 Olson et al, 2017 Sway Balance Amick et al, 2015 C3 Logix Clinical RT % - 79% 61% - 93% Eckner et al., 2015 Eckner et al.,

7 It is recognized however, that abbreviated testing paradigms are designed for rapid sport concussion screening on the sidelines and are not meant to replace a comprehensive neurological evaluation; nor should they be used as a standalone tool for the ongoing management of sport concussion. - McCrory et al, 2017 (Biomarkers) Defined: A characteristic that is objectively measured and evaluated as an indicator of normal biological or pathogenic processes or pharmacologic responses to therapeutic intervention (Biomarkers Definitions Working, 2001) Why? Absence of a gold standard Clinical decision making Treatments Post concussion syndrome Types Serum/Plasma/CSF EEG Neuroimaging (Kulbe et al, 2016) 7

8 (Biomarkers) Biofluids Lactate dehydrogenase Creatine kinase-bb Neuron specific enolase (NSE)(Yang et al, 2013) (Shahim et al, 2014) S-100B (Waterloo et al, 1997) Schulte et al, 2014) Glial fibrillary acidic protein (GFAP)(Papa et al, 2016) Ubiquitin C-terminal hydrolase L1 (UCH-1) (Papa et al, 2016) (Papa et al, 2012) Tau (Olivera et al, 2015) Lactate dehydrogenase Creatine Kinase-BB NSE GFAP UCH-L1 S100B Tau Protracted Recovery Giza et al, 2014 Nelson et al, 2016 (Biomarkers) qeeg Event related potentials P300 Decreased amplitude (Baillargeon et al, 2012) Latency (Parks et al, 2015) Persistent Abnormalities Previous concussion history Advanced neuroimaging fmri DTI Insufficient evidence (McCrory et al, 2017) Parks et al,

9 (Biomarkers) Sport Concussion () Physical rest Symptom based Acute phase of injury Cognitive rest Symptom based Academic adjustments or modifications Rehabilitation Variable (e.g., cervical spine and vestibular therapies) VOMS Mucha et al,

10 Sport Concussion () Sub-symptom threshold based exercise > 90% of sport concussions resolve within 10 days What is atypical recovery? 14 (Covassin et al, 2012) 30 days (Leddy et al, 2017) Anxiety and depression Buffalo Concussion Treadmill Test 1) Diagnose exercise intolerance 2) Exercise prescription Symptom resolution BDNF? Autonomic function Sport Concussion () Buffalo Concussion Treadmill Test Stage Treadmill Grade Treadmill Speed Start 0% 3.3 mph 1 minute 2.0% 3.3 mph 2 minutes 3.0% 3.7 mph 3 minutes 4.0% 4.1 mph Test Termination Symptom exacerbation > 3 pts or RPE > 19 RPE assessed at 1 minute intervals HR and BP assessed every 2 minutes Leddy et al, 2011 & 2013 Sport Concussion () Absolute and relative contraindications Exercise resistance Increased risk for cardiopulmonary disease Significant balance deficits Beta-blocker use Hypertension etc Leddy et al

11 The Future of Sport Concussion Diagnostics Prognostics Theranostics (Broglio et al, 2007) (Register-Mihalik et al, 2011) (Resch et al, 2016) (Meehan et al, 2014) (Lau et al, 2011) (Resch et al, 2015) (Silverberg et al, 2015) (Howell et al, 2016) Symptom phenotypes? The Future of Sport Concussion Athlete 11

12 Personnel Implementation Equipment Documentation Communication Emergency Care Facilities Transportation Venue Location s To date, a gold standard for the assessment of sport concussion does not exist A multidimensional and interdisciplinary remains the recommendation of all governing health care bodies / consensus groups (McCrory et al, 2017) As new clinical measures and management practices associated with sport concussion emerge, clinicians must remain vigilant in the assessment of objectivity, reliability and validity prior to full incorporation into a concussion management protocol 12

13 Thank you! 13