Current Research Perspectives: What We Know Now and Where We Are Headed. Objectives. What We Think We Know?

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1 Current Research Perspectives: What We Know Now and Where We Are Headed Tamara C. Valovich McLeod, PhD, ATC, FNATA John P. Wood, D.O., Endowed Chair for Sports Medicine Professor and Director, Athletic Training Programs Director, Athletic Training Practice-Based Research Network Objectives Review past and current research as it applies to concussion management What we think we know What we don t know Examine methodologies for future research Where the research is headed Knowledge Translation Pharmacology What We Think We Know? Imaging Biomarkers Biomechanics Assessment Outcomes & Clinical Pathways Prevention Rehabilitation Technology Concussion is a significant concern in all sports There is a risk for repeat injury There is a need for physical and cognitive rest Comorbid factors can hinder recovery A multifactorial assessment is best Epidemiology of Pediatric Sport-Related Concussion million concussions annually (Langlois, 2006) 8.9% of all high school athletic injuries (Gessel, 2007) Nationwide estimates of sport-related mtbi hospital charges ~$6 million annually (Yang, 2007) Limited epidemiological data in patients under high school age ~144,000 pediatric (0-19y) patients report to ER (Meehan, 2010) Guskiewicz & Valovich McLeod, 2011 Tamara Valovich McLeod,

Risk of Repeat Injury Short-term SIS Repeat Injury Long-term

Pathophysiology of SIS Repeat Concussion Relatively minor

pressure Herniation through the foramen magnum Brain stem

al, 1983; Wilberger, 1993; Zemper, 1994) 3 times more likely

Increased severity with subsequent concussion (Guskiewicz et

2 Risk of Repeat Injury Short-term SIS Repeat Injury Long-term MCI Depression CTE Giza & Hovda, J Athl Train, Pathophysiology of SIS Repeat Concussion Relatively minor second trauma Loss of autoregulation Increases intracranial pressure Herniation through the foramen magnum Brain stem failure 4-6 times risk for subsequent concussion (Gerberich et al, 1983; Wilberger, 1993; Zemper, 1994) 3 times more likely to sustain 2 nd in same season (Guskiewicz et al, 2000) Increased severity with subsequent concussion (Guskiewicz et al, 2000) Mortality rates near 50% and morbidity rates of 100% Tamara Valovich McLeod,

3 Symptom Severity Control Concussion CRITICAL FIRST WEEK: Average of 7 days for full recovery 75% of repeat concussions within first 7 days 92% of repeat concussions within first 10 days Guskiewicz et al, JAMA 2003 Physical Rest REST Cognitive Rest 5 0 Baseline Injury 2 Hrs Day 1 Day 2 Day 3 Day 5 Assessment Point Day 7 Day 90 Courtesy of Kevin M. Guskiewicz, PhD, ATC Symptom exacerbation following cognitive activity 88.5% of girls and 55.4% of boys experience CEE after concussion (Gioia, unpublished) McCrory, 2013; Broglio, 2014 Rest Activity During Recovery? 1 week of cognitive and physical rest decreased symptoms and increased ImPACT scores regardless of time between concussion and onset of rest (Moser, 2012) 1-7d, 8-30d, 31+ d Patients engaged in higher cognitive loads had longer time until symptom resolution (Brown, 2014) No school or exercise activity School activity only School activity and light activity at home School and sports practice School and sports games Majerske, JAT, 2008 No activity Asleep or comatose Cognitive Rest Goal: limit cognitive activity to a level that is tolerable and does not exacerbate symptoms Full activity Normal school Academic Decline Have you personally encountered a situation where a student athlete that you have treated experienced a decrease in school and academic performance as a direct result of a symptomatic concussion? Yes 79% (n=549) No 21% (n=142) ~44% of concussions resulted in some form of academic accommodations Mayfield, J Athl Train, In press Tamara Valovich McLeod,

School Nurse Perspective Moderately-to-very familiar with AA (3.52/4.0 ± 0.73), IEPs (3.54/4.0 ± 0.70), and 504-plans (3.5/4.0 ± 0.73) 59.4% of student-athletes with concussions have received AA 27.

4 School Nurse Perspective Moderately-to-very familiar with AA (3.52/4.0 ± 0.73), IEPs (3.54/4.0 ± 0.70), and 504-plans (3.5/4.0 ± 0.73) 59.4% of student-athletes with concussions have received AA 27.7% of nurses always (14.4%) or almost always (13.3%) recommend AA 10.5% rarely recommend and 13.4% never recommend AA 30.7% indicated the school did not have an academic support team for concussed studentathletes Weber, 2014 Modifying Factors More Conservative Management McCrory, 2009 ADHD / LD Lower baseline neurocognitive scores for isolated ADHD or LD and combined ADHD+LD (Elbin, 2013) Suggestions for separate norms Prospective study of over 8000 high school student athletes (Shepherd, 2013, abstract) 158 participants (1.8%) indicated they had LDs; 375 (4.3%) noted they had been diagnosed with ADHD 632 concussions (incidence = 7.2%) were diagnosed during the 2-year study period Percentage of Patients * Prior Concussion History * Learning Disability No Learning Disability Newly Diagnosed Concussion Self-reported LD and report of prior and newly diagnosed concussions. *Significantly higher (p<.001). Percentage of Patients * * ADHD No ADHD What We Don t Know Does legislation improve outcome? What are the best assessments? When should post-injury assessments be administered? What magnitude of impact results in concussion? Can we prevent concussion? 0 Prior Concussion History Newly Diagnosed Concussion Self-reported ADHD and report of prior and newly diagnosed concussions. *Significantly higher (p<.001). Tamara Valovich McLeod,

Knowledge is improving (Chrisman, 2012; Bloodgood, 2013) Intent to report remains problematic (Chrisman, 2013; Register-Mihalik, 2013; Mrazik, 2014; Rivara, 2014) Education Washington state

physicians to clear Not all require training in concussion Lack of knowledge (Zonfillo, 2012; White 2013; Stoller, 2014) Illinois pediatricians (Carl, 2014) 27% somewhat or very familiar with law

you are injured You re supposed to play injured Don t want to let team down Hesitant to report to coach Chrisman, 2012 Symptom Inventories Neurocognitive Tests Postural Control Assessments Current

identifying concussion immediately after injury (Sensitivity 80-94%, Specificity 76-91%, multiple class III studies) Paper and pencil and computerized neurocognitive tests have been found useful in

providers is acceptable, but these tests should be interpreted by a neuropsychologist Clinical tests such as the Balance Error Scoring System (BESS) are easy to administer but have low to moderate

5 Does Legislation Improve Outcomes? May 2009 Jan 2014 Education Parent/Athlete Majority (n=30) use information handouts 2 require online training (AZ, OR) 2 refer to CDC web training (GA, IL) 3 encourage NFHS training (RI, VA, WI) Knowledge is improving (Chrisman, 2012; Bloodgood, 2013) Intent to report remains problematic (Chrisman, 2013; Register-Mihalik, 2013; Mrazik, 2014; Rivara, 2014) Education Washington state (Chrisman, 2014) Soccer and football coach knowledge improved Athlete and parent knowledge still lacking Football athletes receive more education than soccer Provider Education All state laws allow physicians to clear Not all require training in concussion Lack of knowledge (Zonfillo, 2012; White 2013; Stoller, 2014) Illinois pediatricians (Carl, 2014) 27% somewhat or very familiar with law 15% used consensus guidelines in practice Concussion Reporting Barriers Athletes know concussions are dangerous Most would still play with symptoms Athletes want to keep playing It s hard to tell if you are injured You re supposed to play injured Don t want to let team down Hesitant to report to coach Chrisman, 2012 Symptom Inventories Neurocognitive Tests Postural Control Assessments Current Assessment Recommendations Best administered as an interview Sensitivity 64% 89%, Specificity 91% 100% Based on multiple Class III studies Standardized Assessment of Concussion (SAC) useful in identifying concussion immediately after injury (Sensitivity 80-94%, Specificity 76-91%, multiple class III studies) Paper and pencil and computerized neurocognitive tests have been found useful in identifying the presence of a concussion in adolescents and adults (Sensitivity 71-88%, one Class II study, multiple Class III studies) Administration by athletic trainers and other healthcare providers is acceptable, but these tests should be interpreted by a neuropsychologist Clinical tests such as the Balance Error Scoring System (BESS) are easy to administer but have low to moderate diagnostic accuracy (Sensitivity 34-64%, Specificity 91%), multiple Class III studies) Computerized forceplate systems, such as the Sneosry Organization Test (SOT) allow for identificyaton of spsecific sensory inputs, however they also have low to moderate diagnostic accuracy (Sensitivity 48-61%, Specificity 85-90%, multiple Class III stidues) Giza, 2013 Tamara Valovich McLeod,

Concussion Assessment Multifactorial Assessment Vestibular - Ocular Postural Control Symptoms Mental Status Broglio, 2014

tools Mobile applications Impact indicators Important part of a thorough clinical exam allowing assessment of the cranial nerves

naming that involves reading a string of numbers on three test cards Measures for saccades, attention, concentration, speech,

77) Slower times, indicating worse performance, in concussed athletes compared to a preseason baseline score Oculomotor Function

audiologists, neurologists, and neuro-opthamologists iportal Neuro-Otologic Test Center (Akhavan, AAOS, 2014) Significantly

6 Concussion Assessment Multifactorial Assessment Vestibular - Ocular Postural Control Symptoms Mental Status Broglio, 2014 Clinical Exam Concussion Assessment Neurocognitive Emerging Assessment Tools Oculomotor Function Oculomotor function Combination tools Mobile applications Impact indicators Important part of a thorough clinical exam allowing assessment of the cranial nerves (II, III, IV, VI) Component of postural control Oculomotor Function King-Devick Test (Galetta, 2011; King, 2013) Rapid number naming that involves reading a string of numbers on three test cards Measures for saccades, attention, concentration, speech, and language Excellent test-retest reliability (ICC=.97) Acceptable internal consistency (Chronbach s alpha= ) Slower times, indicating worse performance, in concussed athletes compared to a preseason baseline score Oculomotor Function Computerized systems Infrared goggles, rotary chairs and other optokinetic devices Expensive systems intended for use by audiologists, neurologists, and neuro-opthamologists iportal Neuro-Otologic Test Center (Akhavan, AAOS, 2014) Significantly lower scores, by 2 standard deviations on at least 3 of the oculomotor or pupillary reflex tests compared to their baseline test scores Tamara Valovich McLeod,

Vision Testing and Training Dynavision D2 Visual, cognitive and gross motor

c3logix.com) NeuroMinder C3 (www.cognisenathleti cs.com) XLNTbrain system (www.

com) Combination Tools Assessment Domains Postural stability, working memory, set

NeuroMinder,: evaluates neural activity through visual imagery testing;

perceptual skills and may be useful in concussion rehabilitation Concussion

(reaction time, attention, inhibition, impulsivity, information processing

for purchase yet No published studies C3 Logix Mobile Apps Biomechanical Sensors No

measuring the force (or velocity or acceleration) following a head impact and

measuring, storing, and exporting vast clinical research data for future study

Adhesive sticker to Any helmeted www.brainsentry.

xhockeyproducts.com/first-alert- Concussion-Sensor-p/heads-upsensor.

7 Vision Testing and Training Dynavision D2 Visual, cognitive and gross motor elements Evaluation, rehabilitation, Sports performance prevention? C3 Logix ( NeuroMinder C3 ( cs.com) XLNTbrain system ( Combination Tools Assessment Domains Postural stability, working memory, set switching, reaction time, learning and static and dynamic visual acuity NeuroMinder,: evaluates neural activity through visual imagery testing; NeuroBalance: postural control using visual stimuli; NeuroTracker: trains perceptual skills and may be useful in concussion rehabilitation Concussion education through online video training, balance assessment, neurocognitive testing (reaction time, attention, inhibition, impulsivity, information processing efficiency and executive function), and emotional indicators (mood, anxiety, stress, and emotionality). Evidence No published studies Several published abstracts In trials, not available for purchase yet No published studies C3 Logix Mobile Apps Biomechanical Sensors No consensus on a concussive injury threshold Impact indicators Sensors capable of measuring the force (or velocity or acceleration) following a head impact and compare this value against a preprogrammed threshold Monitoring systems Capable of measuring, storing, and exporting vast clinical research data for future study Research tool, not ready for end use consumers Device Type Sports Web Address Adhesive sticker to Any helmeted Brain Sentry back of helmet Checklight First Alert Concussion Sensor gforce Tracker Impact Indicator 2.0 InSite Impact Response System Shockbox Smart Impact Monitor X2 Biosystems Skull cap Any helmeted External helmet Ice hockey Concussion-Sensor-p/heads-upsensor.htm Internal or external Any helmeted helmet Chin strap Football, hockey, lacrosse, extreme sports products/impact-indicator/about-theindicator In-helmet Football External helmet Head band or skull cap Adhesive patch behind ear Football, lacrosse, hockey, equestrian, snow sports, BMX Any Any Tamara Valovich McLeod,

Preventing Concussion Protective Equipment Helmets Protect against head and facial injury in high velocity sports Do not reduce the risk of concussions Helmet Covers No protective benefit Concerns

risk Broglio, 2014; Benson, 2009; Halstead, 2001; ACSM, 2011; Hagel, 2005; Mueller, 2008; Sulheim, 2006 Education Concussion symptom video game improved identification in youth hockey players

examination to identify concussion history Have you ever had an injury to your face, head, skull or brain that resulted in confusion, memory loss or headache from a hit to your head, having your

8 Preventing Concussion Protective Equipment Helmets Protect against head and facial injury in high velocity sports Do not reduce the risk of concussions Helmet Covers No protective benefit Concerns with adding weight to helmet (c-spine risk) Headbands Limited research, not encouraged or discouraged Mouthguards Reduces dental and orofacial injuries No evidence to support reduction in concussion risk Broglio, 2014; Benson, 2009; Halstead, 2001; ACSM, 2011; Hagel, 2005; Mueller, 2008; Sulheim, 2006 Education Concussion symptom video game improved identification in youth hockey players (Goodman, 2006) Concussion education increased reporting of concussion symptoms to coaches (Bramley, 2012) Every state concussion law requires education Proper Assessment Good pre-participation examination to identify concussion history Have you ever had an injury to your face, head, skull or brain that resulted in confusion, memory loss or headache from a hit to your head, having your "bell rung" or getting "dinged" while participating in sports or recreational activities? Thorough clinical examination Use of adjunct assessments Appropriate follow-up and RTP Neck Strengthening Overall neck strength was a significant predictor of concussion in high school athletes (Collins, 2014) For every 1 lb increase in neck strength, odds of concussion decreased by 5 % (OR = 0.95, 95 % CI) Greater cervical stiffness and less angular displacement reduced odds of sustaining higher magnitude head impacts (Schmidt, 2014) Did not show that players with stronger and larger neck muscles mitigate head impact severity Where is the Research Going? Neuroimaging and Biomarkers Rehabilitation / Treatments Clinical pathways Identifying best treatments for different clinical presentation Tamara Valovich McLeod,

Clinical Pathways Clinical Pathways Can we predict patient outcomes? Can we determine the best treatments for each patient based on initial clinical presentation?

Migraine Anxiety / Mood Cervical Treatment Pathways Cognitive rest Physical rest Vestibular rehabilitation Medications Cognitivespeech therapy Early exercise Manual

and physical demands Regulate sleep, stress, diet, and mild exercise (1 short walk/day) Anxiety/Mood Overall increase in anxiety, perhaps with sleep disturbance and

complex environments Brought on with rapid head or body movements Vestibular rehabilitation Post-traumatic Migraine Moderate to severe headache with nausea and

fatigue, distractibility, difficulty with vision, pressure behind eyes, trouble focusing Consult with neuro-optometrist, vestibular therapist Rehabilitation with

Collins, 2013 Collins, 2013 Take Home Points There is and will continue to be a lot of research about concussion Assessment and management will change Emerging

9 Clinical Pathways Clinical Pathways Can we predict patient outcomes? Can we determine the best treatments for each patient based on initial clinical presentation? Risk Factors Prior concussions Migraine LD/ADHD Sex Age Medical hx Concussion Immediate clinical presentation Clinical Trajectories Vestibular Ocular Cognitive Migraine Anxiety / Mood Cervical Treatment Pathways Cognitive rest Physical rest Vestibular rehabilitation Medications Cognitivespeech therapy Early exercise Manual therapy Collins, 2013 Targeted Treatments Targeted Treatments Cognitive/Fatigue Difficulty concentrating, overall fatigue, decreased energy levels Reduce cognitive and physical demands Regulate sleep, stress, diet, and mild exercise (1 short walk/day) Anxiety/Mood Overall increase in anxiety, perhaps with sleep disturbance and vestibular issues Treat vestibular issues Begin physical exertion protocols and regulate sleep Vestibular Dizziness, fogginess, nausea, anxiety, overstimulation by complex environments Brought on with rapid head or body movements Vestibular rehabilitation Post-traumatic Migraine Moderate to severe headache with nausea and photosensitivity or phonosensitivity, often exaggerated by physical activity and stress Pharmacologic intervention Ocular Motor Localized, frontal-based headaches, fatigue, distractibility, difficulty with vision, pressure behind eyes, trouble focusing Consult with neuro-optometrist, vestibular therapist Rehabilitation with vision therapy specialist Cervical Headache and neck pain ROM, manual cervical and thoracic mobilization, posture education, biofeedback, soft tissue mobilization Collins, 2013 Collins, 2013 Take Home Points There is and will continue to be a lot of research about concussion Assessment and management will change Emerging products Marketing to end users before research is completed Do your homework and investigate products tmcleod@atsu.edu Tamara Valovich McLeod,

10 SCHOOL RECOMMENDATIONS FOLLOWING CONCUSSION Patient Name: Date of Birth: Date of Evaluation: Referred by: Duration of Recommendations: 1 week 2 weeks 4 weeks Until further notice The patient will be reassessed for revision of these recommendations in weeks. This patient has been diagnosed with a concussion (a brain injury) and is currently under our care. Please excuse the patient from school today due to the medical appointment. Flexibility and additional supports are needed during recovery. The following are suggestions for academic adjustments to be individualized for the student as deemed appropriate in the school setting. Feel free to apply/remove adjustments as needed as the student s symptoms improve/worsen. Attendance Breaks No school for school day(s) Allow the student to go to the nurse s Attendance at school days per week office if symptoms increase Full school days as tolerated by the student Allow student to go home if symptoms do Partial days as tolerated by the student not subside Allow other breaks during school day as deemed necessary and appropriate by school personnel Visual Stimulus Audible Stimulus Allow student to wear sunglasses/hat in school Lunch in a quiet place with a friend Pre printed notes for class material or note taker Avoid music or shop classes Limited computer, TV screen, bright screen use Allow to wear earplugs as needed Reduce brightness on monitors/screens Allow class transitions before bell Change classroom seating as necessary Workload/Multi Tasking Testing Reduce overall amount of make up work, class Additional time to complete tests work and homework No more than one test a day Prorate workload when possible No standardized testing until Reduce amount of homework given each night Allow for scribe, oral response, and oral delivery of questions, if available Physical Exertion Additional Recommendations No physical exertion/athletics/gym/recess Walking in gym class only Begin return to play protocol as outlined by return to activity form Current Symptoms List (the student is noting these today) Headache Visual problems Sensitivity to noise Memory issues Nausea Balance problems Feeling foggy Fatigue Dizziness Sensitivity to light Difficulty concentrating Irritability Student is reporting most difficulty with/in All subjects Reading/Language arts Foreign Language Math Science Music History Using Computers Focusing Listening Other: XXXXXXXXXXXX, MD XXXXXXXXXXXXXXXXXXXX Office (XXX)XXX XXXX Fax (XXX)XXX XXXX I,, give permission for Dr. XXXXXXXXX to share the following information with my child s school and for communication to occur between the school and Dr. XXXXXXX for changes to this plan Parent Signature Date This form may be duplicated or changed to suit your needs and your patients needs.

11 Banner Concussion Conference May 3, 2014 Additional Resources Articles Halstead, M. E., K. McAvoy, et al. (2013). "Returning to learning following a concussion." Pediatrics 132(5): Piebes, S. K., M. Gourley, et al. (2009). "Caring for student-athletes following a concussion." J Sch Nurs 25(4): Sady, M. D., C. G. Vaughan, et al. (2011). "School and the concussed youth: recommendations for concussion education and management." Phys Med Rehabil Clin N Am 22(4): , ix. Valovich McLeod, T. C. and G. A. Gioia (2010). "Cognitive rest: The often neglected aspect of concussion management." Athletic Therapy Today 15(2): 1-3. Web Resources REAP Program: CDC Heads Up for Schools: NY State Education Department: Nationwide Children s Hospital Educator Guide: Nationwide Children s Hospital School Administrator Guide:

Management of the Concussed Adolescent

Management of the Concussed Adolescent Tamara C. Valovich McLeod, PhD, ATC, FNATA John P. Wood, D.O., Endowed Chair for Sports Medicine Professor and Director, Athletic Training Program Director, Athletic