VA/DVBIC TBI Clinical Grand Rounds

Transcription

1 VA/DVBIC TBI Clinical Grand Rounds Incorporating a Multi-Dimensional Approach to the Evaluation and Management of Sports-Related Concussion February 3, 2015, 12:00-1:15 p.m. (EST) Presenter: Tracey Covassin, Ph.D., ATC Associate Professor Director, Undergraduate Athletic Training Education Director, Sports-Related Concussion Laboratory Department of Kinesiology Michigan State University East Lansing, Mich. Moderator: Donald Marion, M.D., M.Sc. Clinical Affairs Senior Advisor Defense and Veterans Brain Injury Center Silver Spring, MD

2 Webinar Details Audio for this webinar is not provided via Adobe Connect - Dial: VANTS Use participant pass code: 49114# This webinar session is being recorded Question-and-answer (Q&A) session - Submit questions via the Q&A box 2

3 Resources Available for Download Today s presentation and Non-VA Evaluation Form will be available for download at the end of the program in the Files box on the screen 3

4 Continuing Education Details All attendees are eligible for 1.0 CEU hours of ACCME, ACCME-NP, ANCC and APA for 100% attendance. In order to qualify for CEUs, the program evaluation and post test must be completed by March 3, 2015 with a passing score of 80%. VHA Attendee Instructions: VHA participants must be preregistered to complete the evaluation and post test in TMS. VHA staff should Christopher.white3@va.gov if you were unable to register before the webinar started. Certificate of completion may be printed through TMS upon successful completion. 4

5 Non-VA Participant Instructions All Non-VA participants seeking CEUs will need to complete and the program s fillable PDF Non-VA Evaluation Form by March 3, Please save and a copy of your completed Non-VA Eval/Post-Test Form to EESEPC@va.gov Your certificate will be sent to you using the address provided on your evaluation form. Questions or concerns should be sent to EPC by at EESEPC@va.gov, or the EES Customer Service by phone at EES.1331 opt 5. Finally, the Non-VA Evaluation Form will be available for download right here on Adobe Connect at the end of today s program. 5

6 Webinar Overview Current consensus statements and position papers recommend a multifaceted approach as a best practice for the assessment and management of sports-related concussion. This approach involves a variety of clinical tools that comprise the clinician s toolbox, including measures of neurocognition, symptoms, balance, reaction time and recently recommended vestibular and ocularmotor measures. At the conclusion of this webinar, participants will be able to: Describe current research regarding sports-related concussion Express the importance of a multifaceted approach to concussion assessment Describe factors that influence concussion outcomes, specifically psychosocial issues Describe the long-terms effects of concussion 6

7 Presenter: Tracey Covassin, Ph.D., ATC Tracey Covassin, Ph.D., ATC Associate professor and certified athletic trainer in the Departments of Kinesiology and Intercollegiate Athletics at Michigan State University Served on the Institute of Medicine and National Research Council Sports-Related Concussion in Youth Committee, which released Sports-Related Concussions in Youth: Improving the Science, Changing the Culture in 2013 Directs a multi-site high school and college sports-concussion outreach program in the mid-michigan area Sports-related research foci include sex and age differences in concussion outcomes, neurocognitive impairments and issues associated with multiple concussions Received funding as a principal investigator from external sources including the National Operating Committee of Standards for Athletic Equipment, National Athletic Trainers Association Research and Education Foundation, NFL Charities, and the Centers for Disease Control and Prevention 7

8 Incorporating a Multi-Dimensional Approach to the Evaluation and Management of Sports-Related Concussion Tracey Covassin, Ph.D., ATC 8

9 Disclosures The views expressed in this presentation are those of the presenter and do not reflect the official policy of the Defense Department, U.S. Government or Michigan State University. The presenter does not intend to discuss the off-label/investigative (unapproved) use of commercial products or devices. The presenter has no relevant relationships to disclose. 9 9

10 Presentation Goals Describe current research regarding sportsrelated concussion (SRC) Express the importance of a multifaceted approach to concussion assessment Describe factors that influence concussion outcomes, specifically psychosocial issues Describe the long-term effects of concussion 10

11 Concussions are heterogeneous. Like snowflakes no two are alike. Photo Source: 11

12 Epidemiology of Sports-Related Concussion According to the Centers for Disease Control and Prevention (CDC), there are about million sports-and-recreational concussions in the U.S. annually (Langlois, Rutland-Brown, & Wald, 2006) Researchers have reported that females have a greater risk and incidence for sports-related concussion than males in comparable sports. (Marar, McIlvain, Fields, & Comstock, 2012; Lincoln et al., 2011; Hootman, Dick, & Agel, 2007; Covassin, Swanik, & Sachs, 2003) 12

13 Service Members U.S. service members sustained nearly 23,000 concussion in That figure represents about 84 percent of all traumatic brain injuries (TBIs) in that population. DVBIC,

14 Service Members Although TBI has become the signature injury of the wars in Afghanistan and Iraq, more than 80 percent of TBIs in the military are not diagnosed in the deployed setting. These TBIs most commonly occur from motor vehicle crashes (privately owned and military vehicles), falls, sports and recreation activities, and military training. DVBIC,

15 Service Members There is no reason to suspect that service members between the ages of 18 and 22 who play intramural or service academy sports have different concussion risks than civilian athletes. 15

16 The Centerpiece of Concussion Management Relying on athletes and military service members to tell someone they are experiencing symptoms Many concussions go unreported/undetected Why? Did not think it was severe enough to get medical attention Did not know the signs and symptoms of concussion Did not want to let teammates/military down Did not know the consequences 16

17 The Evolution of Concussion Assessment and Management Grading scales no longer used! Loss of consciousness (LOC) Rigid, inaccurate cookie-cutter approach How are you feeling? How many fingers do you see? Smelling salts 17

18 Assessment should be comprehensive and rehabilitation/treatment should be targeted. There is no silver bullet for assessing or treating concussion. 18

19 for which a comprehensive, interdisciplinary approach to assessment is needed. Neurocognitive Vestibular Physical Exertion Concussion Ocular Motor Symptoms Collins et al KSSTA; Photos courtesy of University of Pittsburgh Sports Medicine Concussion Program 19

20 AFFECTIVE Sadness Nervousness Feeling more emotional Source: creativecommons.org SOMATIC Vomiting Numbness/tingling Photo courtesy of wamc.amedd.army.mil COGNITIVE-MIGRAINE-FATIGUE Headache, dizziness Difficulty remembering/concentrating Fatigue Sensitivity to light/noise SLEEP DISTURBANCE Trouble falling asleep Sleeping less than usual Photo used with permission from 20 Kontos et al. 2012

21 Key Concussion Symptoms Symptoms vary based on: Injury mechanism, location, individual athlete Headache Most common symptom: ~70% (Lovell et al., 2004) Loss of consciousness (LOC) only occurs in ~6-9% of all concussions (Guskiewicz et al., 2003) Not a reliable predictor of severity/recovery Emerging symptoms: Vestibular (DIZZINESS) 21

22 New Study: On-Field Signs and Symptoms Predict Recovery 87 male high school football players Players divided into two groups: Rapid ( 7 days) = 56 players Protracted ( 21 days) = 31 players 13 on-field signs/symptoms Determined by ATCs/sports medicine physicians Combination of testing, observation and self-report Lau B, Lovell MR, Collins MW, Kontos AP, AJSM,

23 Which On-Field Signs and Symptoms Predicted Longer Recovery? Variables Wald χ 2 OR p 95% CI for OR Dizziness LOC Vomiting On-field DIZZINESS was the BEST predictor of LONGER (>21 days) recovery Athletes who were dizzy at time of injury were 6.3 times more likely to have longer recovery Lau, et al

24 Sport Concussion Assessment Tool (SCAT3) Background questions Symptom Assessment Scale Glascow Coma Scale Maddocks questions Standardized Assessment of Concussion (SAC) Neck examination Balance assessment Coordination test 24

25 Sport Concussion Assessment Tool (SCAT3) SAC It includes measures of orientation, immediate memory, concentration, and delayed recall that add up to 30 points. Lower scores on the SAC indicate more severe cognitive impairment. 25

26 Balance and Coordination Tandem gait (three feet) Balance error scoring system (BESS) Double, single, tandem leg stance Eyes closed Hard and foam surface 20 seconds 26

27 Measuring Cognitive (Functional) Recovery Following Concussion Neurocognitive testing Paper-and-pencil vs. computerized Baseline/prospective methodology 27

28 Computerized Neurocognitive Test Batteries Automated Neuropsychological Assessment Metrics (ANAM) Concussion Sentinel (CogState) Headminder Concussion Resolution Index (CRI) Immediate Post-Concussion Assessment Cognitive Testing (ImPACT) 28

29 The Vestibular/Ocular Motor Screening (VOMS) The VOMS consists of brief assessments in these domains: Smooth pursuits Horizontal and vertical saccades Near point convergence (NPC) Horizontal/vertical vestibular ocular reflex (VOR) Visual motion sensitivity (VMS) 29 Mucha, Collins, Elbin, Furman, Troutman-Enseki, DeWolf, Marchetti, Kontos. (In Press). AJSM.

30 Figure 1. Smooth Pursuits Photo courtesy of University of Pittsburgh Sports Medicine Concussion Program 30 Mucha, et al., (In Press). AJSM.

31 Figure 2. Horizontal and Vertical Saccades Photos courtesy of University of Pittsburgh Sports Medicine Concussion Program Mucha et al. (In Press). AJSM 31

32 Figure 3. NPC Distance (cm)- Avg of 3x Photos courtesy of University of Pittsburgh Sports Medicine Concussion Program Mucha et al. (In Press). AJSM 32

33 Figure 4. Horizontal Vestibular- Ocular Reflex (VOR) Photos courtesy of University of Pittsburgh Sports Medicine Concussion Program Mucha et al. (In Press). AJSM 33

34 Figure 5. Visual Motion Sensitivity (VMS) Photos courtesy of University of Pittsburgh Sports Medicine Concussion Program Mucha et al. (In Press). AJSM 34

35 The Vestibular/Ocular Motor Screening (VOMS) Following each VOMS assessment, patients rate on a scale of zero (none) to 10 (severe) changes in: headache, dizziness, nausea and fogginess symptoms NPC is assessed by both symptom provocation and NPC distance (measured as average of three trials) Normal = <5cm Five min total 35

36 King-Devick Test Two-minute sideline test to identify concussion Evaluates visual tracking and saccadic eye movements Based on the time to perform rapid number scanning/naming on three test cards Retest-reliability (ICC =.97) 36

37 37 Photo courtesy of King-Devick

38 Sway Balance Measures thoracic sway When to administer? Baseline, sideline, and acutely postconcussion (one to three days) Utility and applicability of assessing balance past three days is questionable, as with BESS 38

39 Sway Balance Athletes are instructed to do the following: Remove shoes and keep their eyes closed throughout test Hold device close to chest with both hands for 10 seconds Use five stances Feet together Tandem left foot in front Tandem right foot in front Single leg right leg Single leg left leg 39

40 Sway Balance Photo courtesy of 40

41 Sway Balance Photo courtesy of 41

42 SRC Clinical Trajectories or Subtypes Vestibular Anxiety/ Mood Ocular Concussion Cervical Cognitive/ Fatigue Post- Traumatic Migraine 42 Collins, Kontos, Reynolds, Murawski, Fu. KSSTA; 2014

43 Trajectories Influence Response to Injury Vestibular Dizziness, vertigo, loss of control anxiety Ocular-Motor Vision problems focus, academic problems Often misdiagnosed as cognitive problems, ADHD Cognitive-Fatigue Fatigue, energy issues attentional focus Symptoms worsen throughout the day 43

44 Trajectories and Response (cont.) Post-traumatic migraine Headaches, sleep issues stress, anxiety Anxiety/Mood Hypervigilance worsening/dwelling on symptoms Malingering Cervical Misdiagnosis frustration, loss of control 44

45 Other Things to Consider Trajectories often overlap Timing of interventions is important Acute, sub-acute, chronic An overemphasis on awareness of symptoms can be counterproductive, especially in the first week Anxiety/ Mood Vestibular 45

46 Current Approach Cognitive and physical rest immediately following a concussion followed by gradual return to activity Photo Source: creativecommons.org 46

47 Rest Following Concussion is Standard of Care and Beneficial Current Guidelines (McCrory et al., 2013): Physical and cognitive rest in the first hours Followed by a gradual return to activity as tolerated without symptom provocation Research in sports medicine clinics supports rest (Moser et al., 2012, Brown et al., 2014) Physical and cognitive rest 47

48 Rest We should employ cognitive and physical REST (and accommodations as needed) in the first few days post-injury, but Photo Source: creativecommons.org 48 48

49 Photo Source: creativecommons.org avoid the dark room /shut-down approach. 49

50 Zurich Recommendations Rehabilitation Stage Fx Exercise at Each Stage Objective at Each Stage 1. No Activity Physical and cognitive rest Recovery 2. Light Aerobic Exercise Walk, swim, stationary bike, < 70% of max HR, no resistance training 3. Sport-Specific Exercise Skating drills (hockey), running (soccer), no head impact activities 4. Non-contact drills More complex training drills, may being progressive resistance training 5. Full-contact practice Following medical clearance, participate in normal training activities 6. Return to play Normal game play 50 McCrory et al. (2013) Increase HR Add movement Exercise, coordination, and cognitive load Restore athlete s confidence; coaching staff assesses functional skills

51 Research Overview: History of Concussion(s) Numerous studies have investigated the influence of concussion history on the risk and recovery from future concussion. Three questions have emerged: Does history of concussion predispose athletes to a greater risk of future concussion? Are there prolonged recovery times associated with having a history of concussion? Are their any long-term effects associated with having a history of multiple concussions? 51

52 Question 1: Greater Risk for Future Concussion? Concussed high school and collegiate athletes are three times more likely to sustain another concussion in the same season (Guskiewicz et al. 2000) Dose response for # of previous concussions and risk for incident concussion (Guskiewicz et al. 2003) 3+ (3.4 times) 2 (2.8 times) 1 (1.5 times) 52

53 Question 1 (cont.) History of three-plus and severity of future concussion (Collins et al. 2002) 9.3 times more likely to demonstrate 3-4 abnormal markers On-field LOC (6.7 times), confusion (4.1 times), anterograde amnesia (3.8 times) 53

54 Question 2: Longer to Recover from Subsequent Concussion? No neurocognitive differences between first and second concussion (Macciocchi et al. 2001) Prolonged recovery after three concussions? Several researchers suggest athletes with three or more concussions take longer to recover (Iverson et al. 2004; Guskiewicz et al. 2003; Covassin et al,. 2013) 54

55 Question 3: Long-Term Effects? Surveys of retired professional athletes provide some evidence that a history of multiple concussions increases risk of depression Chronic Traumatic Encephalopathy (CTE) Media coverage (~50 articles on CTE in New York Times since 2005) is ahead of the science! 55 Didehbani et al., 2013; Guskiewicz et al., 2007; Kerr et al., 2012

56 CTE CTE is a form of neurodegeneration believed to result from repeated head injuries Originally termed dementia pugilistica because of its association with boxing Dr. Harrison Martland first coined the term dementia pugilistica in 1928 based on pathologic features including cavum septum pellucidum and large ventricles.(martland HS. Punch Drunk. JAMA 91(15): , 1928) 56

57 CTE Accumulation of tau protein leads to neurodegeneration Pro athletes 18-years-old Football, wrestling, soccer, ice hockey, rugby, baseball Other issues Depression Alcohol Drugs 57

58 CTE Incidence and prevalence of CTE is unclear. (McKee et al., 2014; Gardener et al., 2014) There are a few limitations to this research that should be noted. Most of the studies on CTE have been case reports that lacked proper controls, rendering the results difficult to interpret. 58

59 Post-Concussion Psychological Issues 59

60 Overview of Depression and Concussion Depression occurs in six percent of all patients with mtbi or concussion (Jorge et al, 2004) NFL players with three-plus concussions were three times more likely to develop major depression than those without (Guskiewicz et al., 2007) Emotional response cluster of symptoms (Pardini et al., 2004) Need to disentangle depression symptoms from other post-concussion symptoms (Iverson, 2006) 60

61 Overview Depression Symptoms: Depressed/irritable mood Loss of energy/enthusiasm Fatigue Sleep problems PCS? Post-Concussion Symptoms: Depressed/irritable mood Loss of energy/enthusiasm Fatigue Sleep problems DEPRESSION CONCUSSION 61

62 Mechanisms Depression resulting from psychosocial responses to injury Loss of position Frustration Recovery not knowing Invisible injury Loss of social support Bloom et al., 2007; Kontos et al.,

63 Case Comment: Depression and Concussion I think I m depressed. I mean I m just really sad about not playing and not being with the team again this weekend. I just want to sleep all day, and I m tired all the time. I am so frustrated and wish I could just be me again. 22-year-old, female collegiate volleyball player at 21 days post injury Photo courtesy of Michigan State University 63

64 What Does the Research Say? Depression levels increased post-injury and lingered to 14 days post-concussion Kontos et al., (2012) 64

65 Overview of Anxiety and Concussion Anxiety or nervousness is commonly reported following concussion 17-33% of concussions involve PTSD-like anxiety symptoms (Harvey & Bryant, 2000) Limited research on anxiety in concussion Underlying anxiety disorder is more predictive of PCS than concussion (Meares et al., 2008) 65

66 Mechanisms for Anxiety and Concussion Type and severity of concussion events may play a role, particularly in PTSD-like symptoms Mild concussions with minor symptoms are unlikely to lead to anxiety More dramatic events/mechanisms may lead to PTSD-like, anxiety symptoms 66

67 Case 1 comments 22-year-old male skateboarder frontal lobe impact with concrete brief LOC, PTA symptoms = detached (i.e., foggy, headache anxiety) Creative Commons photo by Andrew Parodi 67

68 Case 1 Comments Five minutes after crash onto pavement I am not sure what happened after I landed. I went into a skid and then the next clear thing I remember is being in the car. I remember everyone was talking and saying I should go to the ER. It was really hazy like a dream, and my head was killing me. Two weeks post-concussion I m really nervous since I wiped. It s all I can think about. I can t concentrate in class, and I feel anxious when I go out. I still have the headaches too. 68

69 Case 2 Comments 17-year-old female, high school soccer player Head to head Brief LOC Symptoms = headache, vision, balance anxiety 69

70 Case 2 Comments Immediately after injury After we collided, I swear I could hear stuff around me. I thought I was dreaming until I heard Jen (teammate) yelling at me. But, I couldn t open my eyes no matter what. I felt like I was frozen or something. I don t think I was out, but I m not sure. My head was killing me, and I just wanted to sleep. One month post concussion I keep seeing the collision- when I close my eyes. It s like I can t stop it it happens when I am in class or whenever. I am really nervous in crowds and jump when there s a loud noise. I wish it would get better. 70

71 Mechanisms (cont.) Anxiety resulting from psychosocial response to injury (Kontos et al., 2004) Loss of control Ambiguity re: recovery, return to play (RTP) Everyday stress from the injury Differentiating among alternate causes (especially pre-morbid) for post-concussion anxiety is important for proper management After all, 24% of healthy individuals report anxiety as a current symptom (Gouvier et al., 1992) 71

72 Case Study LOC and RTP? High school basketball player, 16 years old, history of two concussions, no LD Injured with two minutes left in state finals LOC for less than five seconds Full clinical exam = normal on sideline RTP in same game Baseline 24 hrs 8 days 14 days 30 days 60 days 72

73 Case Study Concussion With LD and Multiple Concussions 19-year-old football player with LD diagnosis, with two unreported concussions, followed by a third reported injury-rotational, brief LOC Baseline 2 days- (1 Dx plus 2) 7 days 14 days* *Athlete was medically redshirted and referred to neuro-specialist. 73

74 Case Study - Overexerting 21-year-old, female soccer player, started to exert too early Baseline 2 days 5 days 10 days* *Athlete began exerting too soon. Symptoms returned and scores dropped - missed 3 more games. 74

75 Thank You Photo courtesy of Michigan State University 75

76 References Bloom, G., Horton, S., McCrory P., & Johnson, K. (2007). Sport psychology and concussion: new impacts to explore. British Journal of Sports Medicine. 38(5), Brown, N.J., Mannix, R.C., O Brien, M.J., Gostine, D., Collins, M.W., & Meehan, W.P. (2014). Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics, 133(2), e299-e304. Collins, M.W., Lovell, M.R., Iverson, G.L., Cantu, R., Maroon, J., & Field, M. (2002). Cumulative effects of concussion in high school athletes. Neurosurgery. 51(5), Collins, M.W., Kontos, A.P., Reynolds, E., Murawski, C.D., Fu, F.H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy, 22(2), doi: /s Covassin, T., Moran, R., & Wilhelm, K. (2013). Concussion symptoms and neurocognitive performance of high school and college athletes who incur multiple concussions. American Journal of Sports Medicine. 41(12),

77 References Covassin, T., Swanik, C., & Sachs, M. (2003). Sex differences and the incidence of concussions among collegiate athletes. Journal of Athletic Training, 38(3), Defense and Veterans Brain Injury Center. (2014). DoD worldwide numbers for TBI. Retrieved from Didehbani, N., Cullum, M., Mansinghani, S., Conover, H., & Hart, J. (2013). Depression symptoms and concussions in aging retired NFL players. Archives of Clinical Neuropsychology, 28(5), Gouvier, W., Cubic, B., Jones, G., Brantley, P., & Quinton, C. (1992). Postconcussion Symptoms and Daily Stress in Normal and Head-Injured College Populations. Archives of Clinical Neuropsychology, 7, Guskiewicz, K.M., McCrea, M., Marshall, S.W., Cantu, R., Randolph, C., Barr, W., et al. (2003). Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. Journal of the American Medical Association, 290(19),

78 References Guskiewicz, K.M., Weaver, N.L., Padua, D.A., & Garrett, W.E., Jr. (2000). Epidemiology of concussion in collegiate and high school football players. American Journal of Sports Medicine. 28(5), Guskiewicz, K.M., Marshall, S., Bailes, J., McCrea, M., Harding, H., Matthews, A., et al. (2007). Recurrent concussion and risk of depression in retired professional football players. Medicine and Science in Sports and Exercise, 39, Harvey, A.G., & Bryant, R.A. (2000).Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 157(4), Hootman, J., Dick, R., & Agel, J. (2007). Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. Journal of Athletic Training, 42(2),

79 References Iverson, G.L., Gaetz, M., Lovell, M.R., & Collins, M.W. (2004). Cumulative effects of concussion in amateur athletes. Brain Injury, 18(5), Iverson, G.L., Brooks, B.L., Collins, M.W., Lovell, M.R. (2006). Tracking neuropsychological recovery following concussion in sport. Brain Injury, 20(3), Jorge, R., Robinson, R., Moser, R., Tateno, A., Crespo-Facorro, B., & Arndt, S. (2004). Major depression following traumatic brain injury. Archives of General Psychiatry, 61(1), Kerr, Z., Marshall, S., Harding, H., & Guskiewicz, K. (2012). Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retire professional football players. American Journal of Sports Medicine, 40(10), Kontos, A.P., & Collins, M.W. (2004). An Introduction to Sports Concussion for the Sport Psychology Consultant. Journal of Applied Sport Psychology, 16(3),

80 References Kontos, A.P., Covassin, T., Elbin, R.J., & Parker, T. (2012). Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Archives of Physical and Medical Rehabilitation, 93(10), Lau, B.C., Kontos, A.P., Collins, M.W., Mucha, A., Lovell, M.R. (2011). Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? American Journal of Sports Medicine, 39(11), Langlois, J., Rutland-Brown, W., & Wald., M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. Journal of Head Trauma Rehabilitation, 21(5), Lincoln, A., Caswell, S., Almquist, J., Dunn, R., Norris, J., & Hinton, R. (2011). Trends in concussion incidence in high school sports: A prospective 11-year study. American Journal of Sports Medicine, 39(5), Lau, B.C., Kontos, A.P., Collins, M.W., Mucha, A., & Lovell, M.R. (2011). Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? American Journal of Sports Medicine, 39(11),

81 References Lovell, M.R., Collins, M.W., & Bradley J. (2004). Return to play following sports-related concussion. Clinical Sports Medicine, 23(3), Macciocchi, S., Barth, J., Littlefield, L., & Cantu, R. (2001). Multiple concussions and neuropsychological functioning in collegiate football players. Journal of Athletic Training, 36(3), Marar, M., McIlvain, N., Fields, S., & Comstock, D. (2012). Epidemiology of concussions among United States high school athletes in 20 sports. American Journal of Sports Medicine, 40(4), McKee, A., & Robinson, M. (2014). Military-related traumatic brain injury and neurodegeneration. Alzheimer s & Dementia, 10(3), S242-S253. McCrory, P., Meeuwisse, W., Aubry, M., Cantu R., Dvořák, J., Echemendia, R., et al. (2013). Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport, Zurich, November Journal of Athletic Training, 48(4),

82 References Meares, S., Shores, E.A., Taylor, A.J., Batchelor, J., Bryant, R.A., Baguley, I.J., et al. (2008). Mild traumatic brain injury does not predict acute postconcussion syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 79(3), Moser, R., & Schatz, P. (2012). Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. The Journal of Pediatrics,161(5), Mucha, A., Collins, M., Elbin, R.J., Furman, J., Troutman-Enseki, C., DeWolf, R., Marchetti, G., & Kontos, A.P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. American Journal of Sports Medicine, 175(7), Pardini, J., Stump, J., Lovell, M.R., Collins, M.W., Moritz, K., & Fu F. (2004). The Post-Concussion Symptom Scale (PCSS): a factor analysis [abstract]. British Journal of Sports Medicine, 38,

83 BESS Photo courtesy of F.A. Davis 83

84 Participants: Overview of the Study 64 patients (M = 13.9, SD = 2.5 years) 5.5 days (SD = 4.0) following a diagnosed sports-related concussion 78 controls (M = 12.9, SD = 1.6 years) Matched on concussion history and age Procedures: Trained clinicians administered these assessments to patients during their initial clinical visit: Vestibular/Ocular Motor Screening (VOMS) Post-Concussion Symptom Scale (PCSS) Balance Error Scoring System (BESS)-concussed only Mucha et al. (In Press). AJSM 84

85 Is the VOMS reliable? Overall VOMS had high internal consistency: Cronbach s alpha = 0.92 All of the items contributed positively to the overall internal consistency Inter-item correlations ranged from 0.44 to 0.88 The lowest inter-item correlations were seen between the NPC distance and VOMS symptom scores, ranging from 0.44 to

86 Summary of Key Findings Nearly 61% of concussed patients report an increase in at least one symptom following the VOMS. Controls report few symptoms following VOMS and have normal NPC distances. VOMS symptom scores >2 and NPC distance >5cm represent clinically useful cut-offs. Three VOMS items (VOR, VMS, NPC distance) resulted in 89% accuracy for identifying patients with concussion. Mucha et al. (In Press). AJSM. 86

87 87 Questions?

88 Continuing Education Details In order to qualify for CEUs, the program evaluation and post test must be completed by March 3, 2015 with a passing score of 80%. VHA participants: Must be preregistered to complete the evaluation and post test in TMS. Christopher.white3@va.gov if you were unable to register before the webinar started. Certificate of completion may be printed through TMS upon successful completion. Non-VA participants: Complete and the program s fillable PDF Non-VA Evaluation Form to EESEPC@va.gov 88

89 Save the Date VA/DVBIC TBI Clinical Grand Rounds Webinar: Orofacial Pain Disorders and the TBI Patient - Think About the Brain" John F. Johnson, DDS, MS CAPT (Ret), DC, USN June 22, :00-1:15 p.m. (EDT) 89

90 VA/DVBIC TBI Clinical Grand Rounds POCs DOD: Sherray Holland, and LCDR Cathleen Davies, VHA and all other federal partners: Christopher White, 90