Disclosure Statement. Objectives 1/18/2016

Transcription

1 In-Office Evaluation of Sports Related Concussion Micky Collins, PhD University of Pittsburgh Medical Center Associate Professor Department of Orthopaedic Surgery Department of Neurological Surgery Program Director UPMC Sports Concussion Program Disclosure Statement Micky Collins, PhD is a Co-Founder and Stakeholder of ImPACT Applications, a computerized neurocognitive test battery designed to assess sports concussion and Mild Traumatic Brain Injury. 2 Objectives 1. Discuss the components of an inoffice evaluation of concussion. 2. Discuss how assessment findings help to establish targeted clinical and rehabilitation pathways for concussion 3 1

2 The UPMC Sports Medicine Concussion Program Department of Orthopaedic Surgery Over 15 years treating concussion Clinical Assessment Approach Vestibular Physical Exertion Concussion Neurocognitive Ocular- Motor Symptoms 5 Clinical Evaluation and Assessment Findings Detailed Clinical Interview Vestibular-Ocular Screening (and/or more extensive evaluation) Computerized Neurocognitive Testing (and/or more extensive NP testing) Exertion Evaluation Establish diagnosis and prognosis Establish clinical and treatment trajectories Establish treatment and rehabilitation plan Academic considerations Exertion level (type, duration, intensity) Specific rehabilitative and treatment plan Return to play expectation and plan 6 2

3 Concussion Clinical Trajectories: A Model for Understanding Assessment, Treatment and Rehabilitation Clinical Trajectories Determined by: Clinical Interview and Symptoms Vestibular-Ocular Testing Neurocognitive Testing Vestibular Exertional Testing Anxiety/ Mood Ocular Concussion Cervical Cognitive/ Fatigue Post- Traumatic Migraine 7 Collins MW, Kontos A, et al, KSST, 2014 Growing Empirical Support Scherer & Schubert, 2009 Alsalaheen, et al, 2010 Mucha, et al, 2014 Heitger, et al, 2009 Ellis, et al, 2015 Master, et al, 2015 Pearce, et al, in press Guskiewicz, et al, 2007 Mainwaring, et al, 2004 Hutchison, et al, 2009 Kontos et al., 2012 Kontos, et al, 2012 McCrea, et al, Treleaven, et al, 1994 Schneider, et al, 2014 Mihalik, et al, 2005 Kontos, et al, 2013 In-Office Evaluation Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing 9 3

4 Why Assess the Vestibular-Ocular Systems? Subjective Complaints of Dysfunction Dizziness*, Fogginess*, Feeling one step behind/detached, Fatigue Motion discomfort, Nausea Environmental sensitivity, Difficulties with sensory integration Anxiety/Irritability Impaired balance Headache, Difficulty focusing, Blurred vision, Difficulty with Math/Reading *Predicts protracted recovery from sports-mtbi Lau, Collins et al, AJSM 2011 Lau, Collins et al, AJSM 2009 Kontos, Collins et al, AJSM UPMC Vestibular/Ocular Motor Screening Form (VOMS) 5 minute physical exam Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM, Symptoms Reported By Patient on 0-10 Point Scale Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM,

5 Fig 1. Smooth Pursuits Ability of the eyes to follow a slowly moving target Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM, Fig 2. Horizontal and Vertical Saccades Ability of the eyes to move quickly between targets Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM, Fig 3. Near Point Convergence (NPC) Distance Ability to view a near target without double vision Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM,

6 Fig. 4. Vestibular-Ocular Reflex (VOR):Horizontal and Vertical Ability to stabilize vision as the head moves 16 Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM, Fig 5. Visual Motion Sensitivity (VMS) Ability to inhibit vestibular-induced eye movements when using vision Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Kontos. AJSM, The Diagnostic Accuracy of the VOR, VMS and NPC (adj. for age) for Predicting Concussed Patients is Excellent (.90 [95% CI= ], p<.001). 3 VOMS Items=.90 Dotted line=.50 or no better than chance Receiver Operating Characteristic Curve Positive Prediction Rate of 90% 18 * Model variables: ln(age), VOR, VMS and NPC distance, dotted line indicates AUC =

7 In-Office Evaluation Clinical Interview Vestibular-Ocular Screening Computerized Neurocognitive Testing 19 Computer-Based Neurocognitive Testing Cogsport (Axon) Headminders (CRI) ANAM CNS Vital Signs ImPACT Computerized Neurocognitive Testing Minute, On-Line Office-Based Tool Concussion Symptom Scale 21 Item Likert Scale (e.g. headache, dizziness, nausea, etc) 8 Neurocognitive Measures Verbal Memory, Visual Memory, Reaction Time, Processing Speed Summary Scores Detailed Clinical Report Outlines Demographic, Symptom, Neurocognitive Data Internal baseline validity checks built into program (demarcates poor effort) On-Line Version Available Extensive normative data available from ages Over 225 peer-reviewed research articles published since 2000 Extensive data published on reliability, validity, sensitivity/specificity, added value, and prognostic ability of test 7

8 Clinical Assessment Approach Vestibular Physical Exertion Concussion Neurocognitive Ocular- Motor Symptoms 22 Using Concussion Clinical Trajectories to Inform Targeted Treatment Pathways Risk Factors Concussion Assessment of Concussion Clinical Trajectories Treatment and Rehab Pathways Previous Concussions Vestibular Migraine Ocular LD/ADHD Cognitive /Fatigue 23 Female Gender Age Motion sensitiivty, Ocular Hx? Migraine Cervical Anxiety/ Mood Collins MW et al, KSST, Thank you 8

9 1/12/2016 Prevention Efforts and Reducing the Risk of Concussion: Are We Making Progress? Steven P. Broglio PhD, ATC Director, NeuroTrauma Research Laboratory University of Michigan Injury Center Disclosures Current Funders Prevention of head impacts in football: The HuTT technique (Phase I), National Football League/Under Armour/GE HeadHealth Challenge II: Innovative Approaches For Identifying And Preventing Brain Injury Prevention of head impacts in American football, National Athletic Trainers Association - Research and Education Foundation The National Collegiate Athletic Association - Department of Defense Grand Alliance: Concussion Assessment, Research, and Education (CARE) Consortium, National Collegiate Athletic Association and USA Medical Research Acquisition Activity (W81XWH : ) National sport concussion outcomes study - Phase 1: The role of equipment and head impact exposure on neurological outcomes, National Collegiate Athletic Association The impact of concussive and sub-concussive blows on brain network activity, The National Institutes of Health: National Institute of Neurological Disorders and Stroke (1R15NS ). Previous Funders Stability and Effect of Concussion on Brain Network Activation Scores, contract with ElMindA, Ltd Concussion across the lifespan: Persistent effects on brain, neurocognitive functioning, and motor control, National Athletic Trainers Association - Research and Education Foundation How to reduce concussion risk? Equipment Rules changes Coaching and Technique Neck Strength Helmet testing circa

10 1/12/2016 Better Equipment Better helmets = lower risk Rowson, J Neurosurg, 2014 Better Equipment Do not appear to reduce ball impact force. (Withnall, Brit J Sport Med, 2005) May be effective in reducing concussions ~50% reduction (Delaney Brit J Sport Med, 2008) Rules changes NCAA 1893 The first leather helmet for football is worn by a player in the Army-Navy game All football players are required to wear helmets No football player may deliberately and maliciously use his helmet or head to butt or ram an opponent Recommended that football helmets meet National Operating Committee on Standards for Athletic Equipment test standards (Required starting with the 1978 season) In football, striking a runner with the crown or top of the helmet added as a foul (ie Spearing rule) NCAA adopts rule changes limiting the number of full-contact practices in football Mandatory review of any flagrant personal fouls for targeting defenseless players or using the crown of the helmet Three-man wedge illegal on kickoffs in football and illegal for a player to go out of bounds to block an opponent Kickoff moved to the 35-yard line 2012 The Ivy League adopts practice rules in lacrosse and soccer to reduce contact. 2

11 1/12/ Rules changes: Practice restrictions Impacts by Session Type: Pre/Post Rule Change Limiting High School contact practices to 2x per week decreases head impact exposure by 42% Funded by NIH-NINDS (1R15NS081691) LINEMEN QUARTERBACKS RECEIVERS, CORNERS, SAFETIES TIGHT ENDS, RUNNING BACKS, LINEBACKERS LINEMEN QUARTERBACKS RECEIVERS, CORNERS, SAFETIES TIGHT ENDS, RUNNING BACKS, LINEBACKERS PRACTICES COMPETITION Broglio et al, J Athl Train, in review Dompier, JAMA Peds, 2015 Rules changes: Checking 64% of NHL concussions resulted from checking Concussion odds are 1.71x when checking allowed in Pee Wee s USA Hockey prohibited body checking in Pee Wee (2011) checking skills taught during practices Emery, Inj Prev, 2010 Changing Technique Arm 1 (Kerr, Ortho J Spts Med 2015) 2108 players (5-15yrs) 704 normal play 663 Heads up Football 741 Heads up Football and Pop-Warner Concussion rates reduced ~70% in practices ~55% in games Arm 2 (Kerr, Ortho J Spts Med 2015) 70 players 38 complete Heads Up training 37% reduction in head impacts 3

12 Fatalities NYT front page 1 st state law NFL lawsuit filed 1/12/2016 Injury Prevention: Neck Strength Force = mass * acceleration or head acceleration = applied force mass Human head weighs ~4.5kg Increasing mass decreases acceleration Does it work? Computer models suggest 35% injury risk reduction (Viano, Neurosurgery, 2005) In male and female athletes across the age spectrum, greater neck strength and anticipatory cervical muscle activation ("bracing for impact") can reduce the magnitude of the head's kinematic response. (Eckner, Am J Sports Med 2014) Greater static neck strength did not mitigate head acceleration (Mihalik, Clin J Sports Med, 2011) The findings did not show that players with stronger and larger neck muscles mitigate head impact severity (Schmidt, Am J Sports Med, 2014) For every one pound increase in neck strength, odds of concussion decreased by 5 % (Collins, J Prim Prev, 2014) Athletes that anticipated the impact had lower post-impact head acceleration (Mihalik, Clin J Sports Med, 2011) Are we making progress? 800 Football Related Deaths Pro/semi-pro College High school Sandlot National Center for Catastrophic Sport Injury Research, 2013 Are we making progress? Figure from D Comstock, Colorado School of Public Health 4

13 1/12/2016 Thank You Funders Prevention of head impacts in football: The HuTT technique (Phase I), National Football League/Under Armour/GE HeadHealth Challenge II: Innovative Approaches For Identifying And Preventing Brain Injury Prevention of head impacts in American football, National Athletic Trainers Association - Research and Education Foundation The National Collegiate Athletic Association - Department of Defense Grand Alliance: Concussion Assessment, Research, and Education (CARE) Consortium, National Collegiate Athletic Association and USA Medical Research Acquisition Activity (W81XWH : ) National sport concussion outcomes study - Phase 1: The role of equipment and head impact exposure on neurological outcomes, National Collegiate Athletic Association The impact of concussive and sub-concussive blows on brain network activity, The National Institutes of Health: National Institute of Neurological Disorders and Stroke (1R15NS ). Colleagues University of Michigan Faculty: James Eckner, MS MD; Deanna Gates PhD; Sean Meehan PhD; Staff: Rick Bancroft, Melissa Pohorence, Ashley Rettmann Graduate Students: Margaret Dowling; Michelle Galdys; Andrew LaPointe, MS; Kate O Connor; Richelle Williams, MS ATC Undergraduates: Tony McKeiver, Rebecca Sigourney Indiana University Tom McAllister, MD Medical College of Wisconsin Mike McCrea, PhD Steven P. Broglio PhD, ATC Director, NeuroTraumaResearch Laboratory broglio@umich.edu 5

14 Treatment and Return to Play Mark Halstead, MD Director, Sports Concussion Clinic Washington University in St Louis Treatment Typically has been recommended for physical and cognitive rest Acutely avoid physical activity Commonly exacerbates symptoms Academic adjustments in school Communication important 504/IEP NOT NEEDED for majority of concussions REDUCE, not eliminate, cognitive activity Treatment May need to limit video games, texting, reading, computer use, TV None of these recommendations are evidence based Use common sense Consideration for restrictions on driving reduced reaction time is issue Unclear how long that should be restricted 1

15 Medications There are no medications that have FDA approval for use for treatment of a pediatric sport concussion All are off-label use Most treatments that have been researched are used in patients with prolonged symptoms Currently only amantadine and hypertonic saline have been studied in pediatric concussion. Melatonin currently being studied Medications Used Headache/Pain Medications NSAIDs, acetaminophen, Tricyclic Antidepressants, topiramate Sleep aids melatonin, trazodone, zolpidem, diphenhydramine Focus/Concentration D-amphetamine, methylphenidate, amantadine What medications are used? Survey of AAP members General Peds, Sports Medicine, Adolescent, Emergency Med, Med-Peds 17% response rate (220 completed surveys) 92% manage concussions in their practice 33% were sideline team physicians Kinnaman KA, et al. Acta Paediatrica,

16 What meds are used? What is done in the ED? Survey of AAP Section on Emergency Medicine Members 265 surveys completed (29% response rate) 99% reported managing concussions Kinnaman KA, et al. Pediatric Emergency Care, 2014 What is done in the ED? 3

17 Treatment Evaluate for and treat co-existing conditions Cervical strain Oculomotor deficiencies Vestibular disorders Depression Anxiety Sleep Hygiene Return to Play Criteria Baseline symptoms/asymptomatic at rest Consider using symptom checklists Gradual increases in physical exertion No return of concussion symptoms with exertion Performing at their pre-injury level in school Off medications used to control their acute symptoms Must account for pre-existing problems Return to Play STEP FUNCTIONAL EXERCISE AT EACH STEP OBJECTIVE 1 No activity Recovery 2 Light aerobic exercise Increaseheart rate 3 Sport-specific exercise Add movement 4 Noncontact training drills Exercise, coordination, cognitive load 5 Full contact practice Restore confidence and assess functional skills 6 Game Play ** One step per day ** If symptoms recur, decrease level and resume when symptoms resolve again 4

18 1/20/2016 American Academy of Pediatrics Conclusions & Guidelines for Clinicians on Sports-Related Concussion Kevin D. Walter, MD, FAAP Medical College of Wisconsin Associate Professor, Depts. of Orthopaedic Surgery & Pediatrics Children s Hospital of Wisconsin Program Director, Pediatric & Adolescent Sports Medicine American Academy of Pediatrics Halstead ME, Walter KD, Council on Sports Medicine and Fitness. Sport-Related Concussion in Children and Adolescents. Pediatrics Sep 2010 National Academies: Institute of Medicine Sports-Related Concussions in Youth: Improving the Science, Changing the Culture 2014 Multidisciplinary committee 1

19 1/20/2016 Conclusions / Recommendations Improve / establish a surveillance system NIH and DOD should support research Including longitudinal studies Scientific evaluation of age-appropriate techniques, rules, play/practice standards Set equipment standards and improve equipment development CHANGE THE CULTURE NFHS Contact Limit Recommendations National Federation of State High School Associations, July 2014 Emergency Action Plan, education, proper equipment fit/care Allow contact <2-3 practices per week Ideally 30mins/day; <60-90mins/week Not consecutive days Preseason May require more contact for teaching If two-a-days only 1 contact Multiple levels of play Monitor state rules for quarters/games per week AAP Tackling in Youth Football Landry G, Meehan W, AAP. Tackling in Youth Football. Pediatrics Nov Unclear what age to allow contact Teach & enforce rules of proper tackling ZERO TOLERANCE for illegal, head-first hits Players and families must decide whether benefits outweigh risk Expand non-tackling leagues Sideline athletic trainers 2

20 1/20/2016 State Laws LaRoche AA, Nelson LD, et al. Sport-related Concussion Reporting and State Legislative Effects. CJSM Jan Compared WI rates with 2013 rates & reporting attitudes Rates similar 16.6% to 15.3% Reporting improved 47.3% to 70.6% In % aware of state law & 55.1% felt it made them more likely to report GUIDELINES & TAKE HOME POINTS Continue to promote education & awareness Can be done in clinic Remove athletes from play immediately for suspected concussion No return to play on the same day as concussion No return to play until asymptomatic Off medications & back at full school No return without written medical clearance 3